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OSTEOTOMY 


AND    OSTEOCLASIS 


DEFORMITIES    OP  THE   LOWER 
EXTREMITIES. 


BY 


CHARLES   T.    POOEE,    M.  D., 

SURGEON   TO    BT.    MARY^   FREE    HOSPITAL   FOE    CHILDREN,    NEW    YOEE!  ;    MEMBER   OF   THE    NEW 
YORK   SURGICAL    SOCIETY,   ETC. 


NEW   YORK: 
D.    APPLETON    AND    COMPANY, 

1,  3,  and  5  BOND  STREET. 
1884. 


Copyright,  1SS4, 
By  D.  APPLETON  AND  COMPANY. 


TO     THE     MEMORY 

OF 

MY     UNCLE, 
CI1AELES    N.    TALBOT,    Esq., 

THIS   VOLUME    IS   DEDICATED, 

A3    A    SLIGHT    TRIBUTE     OP    AFFECTION,     GRATITUDE, 

AND   RESPECT. 


374630 


PREFACE. 


The  author  of  this  volume  has  had  considerable 
experience  both  in  the  mechanical  and  in  the  opera- 
tive treatment  of  the  deformities  considered  in  this 
book. 

That  there  is  a  want  of  a  concise  treatise  on  oste- 
otomy— one  in  which  the  methods  of  operating  and 
the  management  of  the  wound  and  limb  after  sec- 
tion are  considered — there  can  be  no  doubt.  Whether 
the  author  has  succeeded  in  this  purpose  the  reader 
must  determine. 

Much  time  and  reading  have  been  devoted  to  its 
production,  and  he  trusts  that  his  labors  have  not 
been  entirely  in  vain.  Very  free  use  has  been  made 
of  Dr.  Macewen's  excellent  work  on  Osteotomy,  as 
well  as  of  Campenon's  thesis  "  Du  redressement  des 
membres  par  l'osteotomie,"  and  for  which  the  au- 
thor desires  to  express  his  indebtedness. 

He  is  also  under  great  obligations  to  his  friends 
Dr.  W.  T.  Bull,  Dr.  V.  P.  Gibney,  Dr.  F.  Lange,  of 
this  city,  and  to  Dr.  E.  H.  Bradford,  of  Boston,  for 


vi  PREFACE. 

valuable  assistance;  to  Dr.  A.  T.  Cabot,  of  Boston, 
Dr.  E.  M.  Moore,  of  Kochester,  and  Dr.  K.  H.  Whar- 
ton, of  Philadelphia,  for  the  use  of  specimens  and 
wood-cuts ;  to  the  Librarian  of  the  New  York  Hos- 
pital Library,  and  that  of  the  Academy  of  Medicine, 
for  aid  in  looking  up  references ;  and  to  the  publish- 
ers for  the  trouble  they  have  taken  to  meet  his 
views. 

Chaeles  T.  Pooee. 

5  West  Thirtieth  Street, 
New  York,  August  i,  188JJ,. 


CONTENTS. 


CHAPTER  PAGE 

I. — The  Relation  between  Rickets  and  Certain  Deformities  of  the 

Lower  Limbs 1 

II. — Osteotomy 11 

III. — Osteotomy  tor  Deformities  at  the  Dip  Joint    .        .        .        .30 
IV. — Genu  Valgum  ;   its  Etiology  and  Pathology      .        .        .        .TO 

V. — Osteotomy  for  Genu  Valgum 94 

VI.— Genu  Varum.        .         . 12T 

VII. — Osteotomy  for  Anchylosis  of  the  Knee  Joint    .         .         .        .130 

VIII. — Osteotomy  for  Tibial  Curves 136 

IX. — Osteoclasis 149 

X. — Statistics  after  Osteotomies 170 

Bibliography     .        .        .         .        .'\ 1*75 

Index „  185 


LIST  OF  ILLUSTRATIONS. 


FlaiTRE  PAGE 

1.  Adams's  Saw 14 

2.  Osteotome 17 

3.  "           17 

4.  "           17 

5.  6.  Method  of  ascertaining  size  of  Wedge  to  be  removed  in  Cuneiform 

Osteotomy 27 

7.  Sayre's  Line  of  Section  in  Anchylosis  of  Hip  Joint 3S 

8.  Volkmann's               "                   "                     "        39 

9.  Adams's                     "                   "                     "        40 

10.  Gant's                        "    ,               "                     "        41 

11.  Stephen  Smith's       "                  "                    "        42 

12.  Patient  affected  with  Anchylosis  of  Hip  Joint 63 

13.  Result  after  Osteotomy 64 

14.  Patient  affected  with  Anchylosis  of  Hip  Joint 66 

15.  Eesult  after  Osteotomy 67 

17.  Typical  Case  of  Genu  Valgum 71 

18,  19.  Outline  of  Ends  of  Femur  in  a  Case  of  Genu  Valgum 75 

20.  A  Case  of  Genu  Valgum  complicated  with  other  Curves 88 

21.  Ogston's  Line  of  Section  in  Genu  Valgum 96 

22.  Reeves's     "               "                "         "       97 

23.  Chiene's      "               "                 "          "       98 

24.  Macewen's  first           "                 "          "       98 

25.  "          second       "                 "          " 103 

26.  27.  Outline  of  Condyles  before  and  after  Supra-condyloid  Osteotomy. . .  113 

28.  Patient  affected  with  Genu  Valgum 120 

29.  Result  after  Osteotomy 121 

30.  31.  Patient  affected  with  Genu  Valgum 122 

32.  Result  after  Osteotomy 123 

33.  Patient  affected  with  Genu  Valgum 124 

34.  Result  after  Osteotomy 124 

35.  Patient  affected  with  Genu  Valgum 125 

36.  Result  after  Osteotomy 126 

37.  Case  of  Genu  Varum 128 


x  LIST  OF  ILLUSTRATIONS. 

FIGURE  PAGE 

38.  Case  of  Anterior  Curvature  of  the  Tibia 137 

39.  Patient  affected  with  Bow-legs 147 

40.  Result  after  Osteotomy 147 

41.  Patient  affected  with  marked  antero-lateral  curvature  of  the  Tibia 148 

42.  Result  after  Cuneiform  Osteotomy 148 

43.  Rizzoli's  Osteoclast 155 

44.  Result  after  Osteoclasis  with  Taylor's  Osteoclast. 158 

45.  Collin's  Osteoclast 164 

46.  Robin's  Osteoclast 165 

47.  Patient  with  Curvature  of  the  Tibia 167 

48.  Result  after  Osteoclasis. 168 

49.  Patient  with  Curvature  of  the  Tibia 168 

50.  Result  after  Osteoclasis 169 

Plate  I. — Dr.  H.  R.  Wharton's  case.  Parts  after  Inter-trochanteric  Oste- 
otomy— anterior  view To  face  page  52 

Plate  II. — Dr.  H.  R.  Wharton's  case.  Parts  after  Inter-trochanteric  Oste- 
otomy— lateral  view To  face  page  53 

Plate  III. — Dr.  E.  M.  Moore's  case.  Parts  after  Inter-trochanteric  Oste- 
otomy— anterior  view To  face  page  55 

Plate  IV. — Dr.  E.  M.  Moore's  case.  Parts  after  Inter-trochanteric  Oste- 
otomy— lateral  view ,To  face  page  56 

Plate  V. — Dr.  A.  T.  Cabot's  case.  Parts  after  Supra-condyloid  Oste- 
otomy   To  face  page  112 


OSTEOTOMY. 


CHAPTER  I. 

THE  EEL  A  TION  EETWEEN  EICEETS  AND   CEETAIN  DEFORMI- 
TIES OF  THE  LOWER  LIMES. 

Many  of  the  deformities  of  the  lower  limbs  whose 
treatment  is  considered  in  this  volume  have  their 
origin  in  rickets.  It  has  therefore  been  thought  best 
to  devote  a  short  chapter  to  this  disease,  and  to  point 
out  its  connection  with  the  subject  under  considera- 
tion. 

Those  who  are  connected  with  our  large  dispen- 
saries are  well  aware  of  the  prevalence  of  rickets 
among  the  ajyplicants  for  medical  aid.  Whether  it 
is  as  common  in  this  country  as  in  certain  parts  of 
Europe  is  doubtful.  It  is  not  alone  confined  to  the 
children  of  the  middle  and  lower  classes,  but  is  met 
with  among  the  offspring  of  the  wealthy,  not  per- 
haps in  its  more  advanced  stages,  yet  sufficiently  well 
marked  to  be  easily  recognized  if  its  manifestations 
are  carefully  looked  for.  It  is  seen  among  children 
who  have  been  brought  up  in  the  country  as  well  as 
those  who  live  in  crowded  cities,  but  to  a  much  less 
extent.  It  is  a  disease  that  merits  the  careful  atten- 
tion not  only  of  the  surgeon,  but  of  the  general  prac- 


2  OSTEOTOMY. 

titioner,  in  order  that  its  results,  in  deformities  of  the 
long  bones  and  changes  in  the  shape  of  the  chest 
and  pelvis,  may  "be  prevented.  Kickets  is  not  a  dis- 
ease of  the  bone  alone,  but  is  a  constitutional  affec- 
tion, attacking  the  osseous  structures  in  common  with 
every  other  tissue  of  the  body.  It  is  essentially  a 
disease  of  malnutrition.  It  may  be  congenital,  but  it 
usually  first  manifests  itself  in  children  from  six 
months  to  three  years  of  age.  Bad  air,  improper 
food,  and  scanty  clothing  are  its  most  prolific  causes. 
Any  child  may  become  rickety,  no  matter  how  healthy 
it  may  have  been  at  birth,  if  placed  under  any  condi- 
tion that  interferes  with  its  assimilative  powers.  It 
may  be  laid  down  as  a  rule  that  a  healthy  child,  fed 
on  good  mother's  milk,  will  never  develop  this  dis- 
ease. It  is  equally  true  that  not  every  child  who 
suffers  from  malnutrition  will  become  rickety.  Its 
beginning  is  insidious,  with  the  ordinary  symptoms 
of  improper  digestion.  The  little  patient  may  be 
plump,  but  its  muscles  are  flabby  and  its  complexion 
pale  and  unhealthy  ;  large  veins  are  distinctly  seen 
through  the  pasty-looking  skin.  The  bowels  may  be 
loose  or  confined,  more  often  capricious,  a  day  or  two 
relaxed,  then  followed  by  a  period  of  constipation ; 
the  stools  are  white,  curdy-looking,  and  extremely 
offensive ;  the  food  is  often  passed  through  the  ali- 
mentary canal  undigested.  Accompanying  this  de- 
rangement of  the  digestive  apparatus  there  is  profuse 
sweating  of  the  head,  neck,  and  upper  part  of  the 
chest,  worse  at  night.  The  moisture  will  be  seen 
standing  in  large  drops  upon  the  forehead,  and  often 
runs  down  the  face,  and  at  night  the  pillow  is 
drenched  with  it.     While  the  head  and  neck  are  thus 


RICKETS  AND   CERTAIN  DEFORMITIES.  3 

bathed  in  perspiration  the  abdomen  and  lower  limbs 
are  dry  and  hot.  Another  symptom  is  the  desire  of 
the  child  to  keep  cool  at  night.  It  constantly  throws 
the  clothes  off  from  its  feet  and  limbs,  no  matter  how 
cold  the  temperature  may  be.  The  child  soon  loses 
its  activity,  and  seems  only  happy  when  left  alone. 
It  will  sit  for  hours  almost  motionless,  is  petulant, 
and  cries  on  beino;  moved.  The  desire  to  be  let  alone 
is  due  to  tenderness,  more  or  less  marked,  of  the 
bones,  so  that  any  pressure  on  them  is  painful  to  the 
little  one,  and  it  dislikes  to  be  handled. 

Dentition  in  those  affected  with  rickets  is  usually 
retarded,  or,  if  the  teeth  have  made  their  appearance, 
they  soon  become  black  and  fall  out,  or  are  early  at- 
tacked with  caries.  Jenuer  states  that  if  the  ninth 
month  passes  without  the  appearance  of  a  tooth,  the 
cause  should  be  carefully  inquired  into,  and  will  al- 
most always  be  found  in  rickets.  According  to  Eus- 
tace Smith,  the  symptoms  of  rickets  seldom  appear 
before  the  fourth,  and  usually  not  until  the  seventh 
month.  Cases,  however,  occur  in  which  the  advent 
of  the  disease  is  delayed  much  longer.  Jenner  men- 
tions a  girl  of  nine  years  of  age  in  whom  the  symp- 
toms of  rickets  had  just  commenced. 

Enlargement  of  the  spleen,  liver,  and  of  the  lym- 
phatic glands  in  different  portions  of  the  body  is  a 
common  accompaniment  of  this  disorder.  In  some 
cases  the  patient  is  reduced  to  a  skeleton,  while  in 
others,  as  mentioned  before,  it  retains  its  plumpness. 

While  the  symptoms  mentioned  above  are  mani- 
festing themselves,  changes  are  taking  place  in  the 
bones,  perhaps  not  more  profound,  yet  more  notice- 
able than  in  any  other  structure  of  the  body.     One 


4  OSTEOTOMY. 

of  the  earliest  of  these  is  a  beaded  appearance  at  the 
sterno-costal  junction  and  an  enlargement  of  the  epi- 
physes, especially  those  at  the  wrist-joint.  If  a  child 
aifected  with  rickets  be  carefully  examined,  a  line  of 
nodules  will  be  felt,  and  often  seen,  marking  the  point 
of  junction  between  the  ribs  and  the  sternnm.  This 
condition  has  been  noticed  in  children  suffering  from 
rickets  six  weeks  after  birth.  When  this  beading 
of  the  ribs  is  found,  it  is  a  positive  proof  of  the  exist- 
ence of  this  disease.  There  are  also  certain  altera- 
tions in  the  occipital  bone,  often  found  at  a  very  early 
stage  of  the  disease  in  young  children.  Macnamara 
states  that  they  are  almost  as  constant  a  condition  in 
this  disease  as  the  abnormalities  of  the  ribs,  but  they 
are  not  as  easily  detected.  If  the  occipital  bone  be 
carefully  examined  in  young  infants  affected  with  this 
disease,  there  will  often  be  felt  several  small,  round, 
or  oval  soft  spots,  situated  within  the  sutural  mar- 
gins of  the  occipital  and  parietal  bones.  These  spots 
are  unossiiied  portions  of  the  structures  from  which 
the  bone  is  produced.  The  number  of  these  spots 
varies  considerably.  The  occipital  bone  is  often  re- 
markably thin  in  cases  of  this  disease,  and  the  head 
has  a  peculiar  elongated  appearance,  while  the  face 
in  marked  cases  remains  small.     (Macnamara.) 

While  these  changes  are  going  on,  others  of  as 
marked  a  character  are  taking  place  in  the  ends  and 
shaft  of  the  long  bones.  The  epiphyses  become  en- 
larged, and  the  shaft  softened  so  that  it  is  often  bent, 
and  the  epiphyses  may  become  twisted,  according  to 
the  intensity  of  the  disease  and  the  force  acting  on 
the  plastic  bone.  The  condition  of  the  bones  varies 
with  the  stage  and  the  intensity  of  the  disease,  and 


RICKETS  AND   CERTAIN  DEFORMITIES.  5 

whether  the  brunt  of  the  changes  falls  upon  the 
epiphyses  or  the  diaphyses.  At  first  the  bones  may 
be  soft,  so  that  they  can  be  bent  like  cartilage ;  later 
they  become  very  hard  and  deformed. 

The  pathological  changes  taking  place  in  the 
bones  are  well  described  by  Macnamara  in  his 
work  "  On  Disease  of  the  Bones  and  Joints."  He 
says :  "  If  a  rickety  bone  be  divided  longitudinally 
during  the  first  stage  of  rickets,  the  medulla  filling 
the  central  canal  and  cancellated  tissue  will  be 
found  to  be  of  a  crimson  color  and  jelly-like  con- 
sistency, this  soft  medulla  being  especially  abundant 
at  the  line  of  the  junction  between  the  diaphysis 
and  epiphysis.  The  medulla  of  a  child  suffering 
from  the  first  stage  of  rickets  consists  of  a  vast 
number  of  round  cells,  compound  cells,  and  fat ;  the 
adenoid  tissue  and  vessels  are  normal  in  appear- 
ance ;  in  fact,  the  elements  characteristic  of  healthy 
medulla  are  present  in  the  bones  of  infants  suffer- 
ing from  this  disease,  but  there  is  an  imperfect  for- 
mation of  the  calcareous  skeleton  of  the  bones,  and 
in  its  place  we  find  an  excess  of  medullary  tissue. 
.  .  .  The  malad}7,  so  far  as  the  bones  are  con- 
cerned, depends  on  the  deficiency  of  earthy  matter 
contained  in  this  hyaline  matrix.  If  a  section  made 
through  the  epiphysis  into  the  diaphysis  be  exam- 
ined during  the  first  stage  of  the  disease,  there  will 
be  found  at  the  line  of  ossification  numerous  villous- 
like  processes  of  medulla,  projecting,  as  it  were,  from 
the  diaphysis  into  the  epiphyseal  cartilage.  These 
processes,  however,  are  not  formed  from  the  growth 
of  the  medulla  of  the  diaphysis  into  the  cartilage, 
but  from  a  transformation  of  the  cartilage-cells   of 


q  OSTEOTOMY. 

the  epiphysis  into  medullary  tissue  at  the  normal 
line  of  ossification.  The  mass  of  the  descendants 
of  the  cartilage-cell  forming  the  processes  referred 
to  are  incapable  of  producing  healthy  bone,  in  con- 
sequence of  a  deficiency  of  the  bone-earth.  So  long 
as  an  infant  is  insufficiently  supplied  with,  or  is  in- 
capable of  assimilating,  elements  necessary  to  the  cal- 
cification of  the  cartilage-cells,  it  is  impossible  that 
healthy  bone  can  be  produced." 

The  changes  in  the  shaft  of  the  long  bones,  ac- 
cording to  Virchow,  "  consist  in  the  non-solidification 
of  the  fresh  layers  as  they  are  formed,  while  the  old 
layers  of  bone  are  consumed  by  normally  progressive 
formation  of  medullary  cavities.  The  periosteum  is 
thickened  and  more  adherent  to  the  bone.  Medul- 
lary spaces  and  vessels  are  met  with  where  normally 
and  properly  not  a  single  medullary  cell  and  scarcely 
a  single  vessel  ought  to  be  found." 

During  the  height  of  the  disease,  when  the 
changes  in  the  bones  are  marked,  they  can  be  bent 
by  the  least  possible  force,  and  their  spongy  por- 
tions may  be  easily  cut  with  a  knife.  In  rickets 
the  ligaments  are  often  altered  in  their  structure, 
so  that  they  may  become  easily  elongated,  and  thus 
permit  lateral  motion  in  joints  in  which  normally 
it  does  not  exist.  However  profound  the  changes 
in  the  bones  may  have  been,  as  soon  as  the  child 
begins  to  masticate  and  is  able  to  assimilate  proper 
nutriment,  the  vast  number  of  bone-cells  rapidly 
take  up  the  earthy  salts  from  the  blood,  and  very 
dense  bone  is  speedily  produced,  so  that  in  a  short 
time  the  bone  may  become  very  hard.  Again,  the 
process  of  sclerosis  may  be  much  slower,  depending 


RICKETS  AND   CERTAIN  DEFORMITIES.  ? 

upon  the  power  of  the  child  to  assimilate,  and  the 
quality  of  the  food  furnished.  Rachitic  changes  in 
the  osseous  structure  do  not  always  take  place  in  all 
the  bones  of  the  skeleton  in  equal  degree,  nor  in 
every  portion  of  an  individual  "bone.  Thus  soften- 
ing may  be  more  marked  at  the  epiphysis  while  in 
the  shaft  it  is  slight,  or  the  shaft  may  show  more 
advanced  changes  than  the  articular  ends.  The 
enlargement  of  the  epiphyses  is  not  an  index  of 
the  changes  in  the  shaft.  The  bone  of  one  limb 
may  be  quite  soft  while  that  of  the  other  is  hard. 
I  have  met  with  this  condition  quite  frequently  in 
operating;  one  tibia  has  been  found  very  easy  to 
divide,  while  in  the  other  section  was  difficult.  The 
fibula  has  been  found  to  be  much  harder  than  the 
tibia  in  the  same  limb. 

Perhaps  the  existence  of  different  deformities  may 
be  due  in  part  to  this  irregularity  in  the  portion  of 
the  bone  on  which  the  intensity  of  the  rachitic  pro- 
cess falls. 

All  writers  on  this  disease  divide  it  into  a  pre- 
liminary stage,  one  of  softening  and  one  of  sclerosis. 
It  is  in  the  latter  that  the  bone-cells  take  up  from 
the  blood  the  earthy  matter  that  gives  bone  its 
hardness.  It  will  be  evident  that  this  stage  can  not 
begin  until  the  child  is  able  to  digest  and  assimi- 
late appropriate  food.  No  rule  can  be  laid  down 
as  to  the  length  of  time  that  the  soft  stage  of  rickets 
lasts,  nor  the  rapidity  with  which  the  hardening 
may  advance.  Each  case  must  be  judged  by  itself. 
The  general  health,  ruddy  appearance,  and  firm  con- 
dition of  the  muscles  are  the  best  guide.  It  may 
take  many  years  in  children  of  low  vital  powers  for 
2 


8  OSTEOTOMY. 

the  bones  to  become  firm,  while  in  others  it  may  be 
accomplished  in  a  few  months. 

There  is  a  condition  described  by  some  observers 
(Barlow,  Page1),  as  "acute  rickets."  It  occurs  in 
children  under  two  years  of  age.  There  is  profuse 
sweating  about  the  head,  changes  in  the  epiphyses, 
and  other  symptoms  usually  found  in  rickets,  to- 
gether with  swelling  and  great  tenderness  of  the 
lower  extremities,  due,  it  was  supposed,  to  an  effu- 
sion of  blood  under  the  periosteum  and  between 
the  deeper  muscular  layers.  Barlow  considers  it  a 
combination  of  rickets  and  scurvy.  By  change  of 
diet,  fresh  air,  and  compression  of  the  limbs,  recov- 
ery may  take  place  rapidly. 

The  age  beyond  which  rickets  is  not  developed 
is  uncertain,  but  probably  in  the  vast  majority  of 
cases  not  after  the  fifth  year.  Some  writers  consid- 
er that  this  disease  may  be  developed  between  the 
twelfth  and  twentieth  years ;  that  is,  during  the  pe- 
riod of  rapid  growth.  Mace  wen  is  an  advocate  of 
this  late  appearance  of  rickets.  But  it  is  denied  by 
the  majority  of  writers.  In  the  chapter  on  genu 
valgum  the  cases  of  MacewTen  are  given.  I  have 
never  met  with  a  case,  and  I  think  if  they  ever 
occur  it  must  be  exceptional.  Deformities  about 
the  knee-joint  are  sometimes  developed  in  persons 
from  twelve  to  twenty  years  of  age,  but  I  think 
that  their  cause  can  be  explained  without  attribut- 
ing them  to  rickets.  In  the  cases  that  I  have  had 
the  opportunity  to  examine  there  w7as  absolutely 
no  symptom  of  rickets  except  the  bending  of  the 
bone  at  the  ej:)iphyseal  line.     Most  of  the  deformi- 

1  "Brit.  Med.  Jour.,"  March  31,  1883,  p.  619. 


RICKETS  AND    CERTAIN  DEFORMITIES.  9 

ties  of  the  lower  limb  are  developed  during  the 
period  of  rapid  growth.  They  are  met  with  first 
iu  infantile  life,  when  all  the  nutritive  processes  are 
at  their  height,  and  the  child  rapidly  increases  in 
weight  and  stature.  This  period,  as  a  rule,  does 
not  extend  beyond  the  seventh  year.  Then  comes 
a  time,  extending  from  the  seventh  to  the  twelfth 
year,  during  which  growth  is  much  slower  and  de- 
formities are  seldom  developed.  From  the  twelfth 
to  the  twentieth  year  is  another  period  of  growth 
and  development  during  which  the  long  bones  rap- 
idly increase  in  length  by  the  deposit  of  osseous 
material  at  their  extremities,  and  which  is  finally 
completed  by  the  consolidation  of  the  epiphyses  and 
diaphyses.  In  this  period,  again,  certain  deformi- 
ties, especially  about  the  knee-joint,  are  developed 
in  those  who  are  compelled  to  labor  hard  and  un- 
dergo fatigue. 

During  the  first  period  bending  of  the  shaft  of 
the  long  bones,  with  the  consequent  deformities,  are 
common,  while  in  the  last  period  deformities  having 
their  origin  near  the  joints  are  met  with,  and  curva- 
tures of  the  shaft  of  the  bones  are  seldom  if  ever  seen. 

The  connection  between  rickets  and  deformities  of 
the  bone  is  one  of  cause  and  effect.  I  do  not  think 
that  the  muscles  exert  an  active  influence,  but  that 
position  and  weight  are  the  cause  of  the  abnormal 
shape  of  the  bones. 

In  this  very  imperfect  review  of  the  symptoms  of 
rickets,  as  it  affects  the  bones  of  the  extremities,  noth- 
ing new  is  claimed,  the  object  being  simply  to  call  at- 
tention to  this  most  prolific  cause  of  deformities. 

While  the  bones  are  soft,  any  abnormal  change  in 


10  OSTEOTOMY. 

their  shape  can,  and  should,  be  corrected  by  appro- 
priate apparatus.  But  after  sclerosis  has  taken  place, 
or  even  is  well  advanced,  orthopedic  appliances  will 
not  correct.  I  am  not  a  believer  in  the  spontaneous 
cure  of  bending  of  the  long  bones.  We  often  hear 
the  advice  given  to  mothers  by  members  of  the  pro- 
fession not  to  submit  these  cases  to  treatment ;  that 
the  child  will  "  outgrow  "  the  malposition;  and  I  wish 
to  enter  a  protest  against  such  advice,  as  it  will  only 
lead  to  disappointment. 


CHAPTER    II. 


OSTEOTOMY. 


"  Osteotomy,"  says  Macewen,  "  in  its  broadest  ac- 
ceptation, may  be  defined  as  a  section  of  bone.  It 
has,  however,  been  regarded  in  a  much  more  restrict- 
ed sense,  the  term  being  applied  to  such  divisions  of 
bone  as  have  been  proposed  and  undertaken  for  the 
relief  of  deformity,  for  the  rectification  of  badly  united 
fractures,  and  for  the  straightening  of  limbs  affected 
with  osseous  anchylosis,  which  are  fixed  in  a  bad  po- 
sition."    ("  Osteotomy,"  p.  37.) 

Section  of  the  long  bones  for  deformity  had  been 
proposed  by  many  early  writers  on  surgery,  yet  it 
does  not  appear  to  have  been  put  in  practice  until 
1815,  when  Le  Mercier  made  a  section  of  the  tibia 
with  a  saw  for  a  badly  united  fracture  of  that  bone ; 
and  in  the  following  year  Wasserfuhr  practiced  the 
same  operation  upon  the  femur.  Barton,  in  1826,  per- 
formed an  osteotomy  just  below  the  trochanter  major 
for  anchylosis  with  flexion  of  the  thigh,  through  an 
open  wound,  the  division  being  made  with  the  saw. 
In  1834  Clemot  removed  a  wedge-shaped  piece  of 
bone  for  the  correction  of  an  angular  deformity  of  the 
femur.  Portal,  Ashley  Cooper,  Warren,  of  Boston, 
and  others,  performed  similar  operations.  All  sec- 
tions of  bones  prior  to  1852  were  performed  through 


12  OSTEOTOMY. 

an  open  wound.  In  that  year  Langenbeck  made  a 
division  of  the  femur  for  anehylosis  of  the  hip-joint 
by  perforating  the  bone  with  a  drill  through  a  small 
wound  in  the  soft  parts,  and  then,  introducing  a  nar- 
row saw,  divided  the  bone.  He  gave  to  this  opera- 
tion the  name  of  subcutaneous  osteotomy. 

In  1868  L.  Stromeyer  Little  made  use  of  a  car- 
penter's chisel  to  divide  the  bone  in  a  case  of  osseous 
anchylosis  of  the  knee-joint,  working  through  a  small 
wound  half  an  inch  in  length.  In  the  following  year 
Mr.  William  Adams  performed  the  operation  of  sub- 
cutaneous section  of  the  neck  of  the  thigh-bone,  known 
as  Adams's  operation.  In  1875  Volkmann1  operated 
antiseptically  on  two  cases  of  anchylosis  of  the  knee- 
joint,  and  in  April  of  the  same  year  Macewen  per- 
formed a  similar  operation.  Ogston,  May  17,  1876, 
divided  the  internal  condyle  of  the  femur  with  a 
saw  in  a  case  of  genu  valgum,  and  Reeves  2  March  17, 
1878,  made  a  section  of  the  internal  condyle  in  Og- 
ston's  line  with  an  osteotome.  And  on  February  2, 
1878,  Macewen  first  performed  the  operation  above 
the  condyle. 

Prior  to  1875  all  osteotomies  were  performed 
through  an  open  wound,  and  were  followed  by  sup- 
puration more  or  less  profuse.  In  the  earlier  opera- 
tions no  attempt  was  made  to  obtain  primary  union 
of  the  soft  parts.  Barton  states  that  it  was  not  de- 
sired. 

Langenbeck's  operation  does  not  seem  to  have 
been  a  great  improvement  upon  those  performed 
through  an  open  wound,  as  deep-seated  suppuration 

1  "Edinb.  Med.  Jour.,"  March,  1875,  p.  794. 

2  "  Brit.  Med.  Jour.,"  September,  21,  1378,  p.  431. 


OSTEOTOMY.  13 

is  admitted  to  have  frequently  followed,  and,  as  the 
only  object  in  his  method  was  to  prevent  such  an 
occurrence,  it  failed  in  its  object.  Moreover,  deep 
suppuration,  with  a  small  outlet  for  the  discharge,  is 
more  productive  of  injury  than  suppuration  in  an 
open  wound.  It  was,  however,  an  advance  toward 
a  better  method  of  operation — namely,  the  subcuta- 
neous way  in  which  osteotomy  is  now  performed, 
and,  as  such,  merits  a  place  in  the  history  of  osteoto- 
my. There  was  also  at  this  time  another  revolu- 
tion taking  place  in  surgical  practice,  which  has  con- 
tributed more  to  its  advance  within  the  last  ten  years 
than  any  one  circumstance,  and  that  was  the  method 
of  treatment  of  wounds  advocated  by  Mr.  Lister. 

It  was  only  on  account  of  the  safety  which  this 
method  of  wound  management  seemed  to  afford  that 
surgeons  felt  justified  in  operating  upon  tissues,  with 
which  their  predecessors  considered  it  too  hazardous 
to  interfere.  Although  much  of  the  technique  of 
strict  Listerism  has  been  abandoned,  yet  its  funda- 
mental principles  have  stood  the  test  of  time — 
namely,  that  on  perfect  cleanliness,  thorough  drain- 
age, and  absolute  rest,  depend  the  best  results  in 
every  operation.  That  osteotomy  has  obtained  its 
place  as  a  safe  and  justifiable  procedure  is  due  to 
the  influence  of  Listerism. 

The  instruments  requisite  for  an  osteotomy  are 
few.  It  may  be  performed  with  a  saw,  chisel,  or  os- 
teotome. Mr.  Adams's  saw,  which  may  be  taken  as 
a  type  of  such  instruments,  he  describes  as  follows : 
It  is  three  eighths  of  an  inch  wide,  with  a  cutting 
edge  an  inch  and  a  half  in  length,  at  the  end  of  a 
slender  shank  three  inches  long.     He  at  first  had  a 


14 


OSTEOTOMY. 


straight  handle,  but  later  substituted  a  curved  one, 
as  being  easier  to  grasp.  The  saw  has  a  round,  blunt 
end,  in  order  not  to  injure  the  tissues  behind  the 
bone.     (Fig.  1.) 

Dr.  George  F.  Shrady,  of  this  city,  has  modified 


Fig.  1. — Adams's  Saw  reduced  one  half,  and  the  cutting  edge. 

Adams's  saw  by  making  it  more  probe-pointed,  and 
has  an  arrangement  by  means  of  a  trochar  and  ca- 
nula,  so  that  in  introducing  the  saw  all  danger  of 
any  injury  to  the  vessels  and  soft  parts  is  obviated. 


OSTEOTOMY.  15 

The  instrument  consists  of  first  a  trochar  and  ca- 
nula — the  former  is  of  the  same  size  and  shape  as 
the  saw.  The  canula  has  a  fenestra  corresponding 
in  position  to  the  teeth  upon  the  saw.  The  method 
of  using  it  is  as  follows :  The  trochar  and  canula 
are  thrust  down  by  the  side  of  the  bone  to  be  di- 
vided— the  instrument  being  held  in  such  a  position 
that  the  fenestrated  portion  of  the  canula  shall  rest 
upon  the  bone  at  the  point  of  desired  section  ;  the 
trochar  is  then  withdrawn  and  is  replaced  by  the 
saw ;  the  former  is  then  removed,  leaving  the  saw  in 
position.  After  the  bone  has  been  sufficiently  di- 
vided the  canula  is  passed  down  over  the  saw  and 
both  are  removed. 

It  is  claimed  that  with  this  instrument  the  dan- 
ger of  injuring  the  soft  parts  is  reduced  to  a  mini- 
mum. I  have  never  used  it,  but  those  who  have 
speak  well  of  it.  The  objections  to  the  use  of  the 
saw  in  osteotomies  are :  It  is  harder  to  work,  it  takes 
a  much  longer  time  to  make  the  section,  there  is 
more  disturbance  of  the  surrounding  tissues,  and, 
theoretically,  the  dust  from  the  saw  is  liable  to  lead 
to  suppuration,  an  objection  that  has  not  been  sus- 
tained by  practice.  Wounds  after  the  use  of  a  saw 
heal  kindly,  and  the  bone-dust  does  not  give  any 
subsequent  trouble.  The  method  of  using  the  saw 
for  making  section  is  as  follows :  An  incision  is  made 
just  large  enough  to  easily  admit  the  instrument  down 
to  and  by  the  side  of  the  bone  to  be  divided.  The 
saw  is  then  passed  down  upon  the  knife  as  a  guide, 
and  the  bone  divided  through  the  greater  part  of  its 
thickness.  The  saw  is  then  removed,  a  sponge  damp- 
ened with  carbolized  water  placed  over  the  wound 


16  OSTEOTOMY. 

to  prevent  the  entrance  of  air,  and  the  remainder  of 
the  bone  fractured.  The  wound  is  to  be  treated  in 
the  same  manner  as  one  after  an  osteotomy  performed 
with  the  chisel. 

In  what  experience  I  have  had  with  the  saw  in 
tibial  curves  it  has  not  seemed  to  me  to  be  as  good 
an  instrument  as  the  osteotome.  It  is  more  difficult 
to  work,  and  it  takes  a  much  longer  time  to  complete 
a  section.  Thus  the  time  necessary  to  divide  the 
neck  of  the  femur  varies  from  five  to  twenty-five 
minutes,  and  there  is  no  doubt  but  that  the  soft  parts 
are  more  or  less  lacerated  by  the  teeth  of  the  instru- 
ment. Shrady's  saw  may  do  away  with  this  latter 
objection. 

A  chain-saw  has  been  used  to  make  the  section. 
Barwell  has  advocated  its  use  within  the  past  year. 

Osteotomy  with  an  Osteotome. — There  are  two 
forms  of  cutting  instruments  of  the  chisel  order — one 
having  both  planes  gradually  sloping  down  to  a 
sharp  cutting  edge,  the  other  made  like  a  carpenter's 
chisel.  To  the  former  Macewen  has  given  the  name 
of  osteotome,  to  distinguish  it  from  the  latter,  which 
is  properly  a  chisel.  The  osteotome  is  an  instrument 
having  its  two  flat  surfaces  gradually  sloping  down 
to  a  sharp  cutting  edge,  like  a  long,  slender  wedge, 
resembling  a  knife-blade,  being  as  thin  as  it  ap- 
proaches the  cutting  surface  as  is  safe. 

The  accompanying  cuts  (Figs.  2  and  3)  represent 
two  views  of  an  osteotome.  They  are  reduced  one 
half  actual  size.  Fig.  2  shows  the  gradual  slope  of 
the  flat  surfaces,  while  Fig.  3  represents  the  latter. 
Fig.  4  is  a  smaller  osteotome  useful  for  division  of 
the  fibula  and  similar  bones. 


OSTEOTOMY. 


17 


It  should  have  a  temper  between  that  of  a  cold 
chisel  and  a  carpenter's  cutting  tool,  so  that  the  edge 
will  not  be  turned  by  the  hardness  of  the  bone,  or  so 


Fig.  2. 


Fig.  3. 


Vy 


brittle  as  to  chip.  It  is  well  always  to  test  the  in- 
strument on  a  piece  of  hard  bone,  driving  it  in  with 
a  pretty  strong  blow  with  a  mallet.  If  the  edge  is 
neither  turned  nor  nicked,  it  is  of  a  proper  temper. 
The  cutting  edge  should  be  very  sharp.     It  should 


18  OSTEOTOMY. 

be  marked  on  the  flat  surface  every  half-inch  from 
the  edge,  in  order  that  the  distance  that  the  instru- 
ment has  penetrated  the  bone  may  be  known.  A 
large  handle  is  also  of  advantage,  as  it  can  be  grasped 
more  easily.  The  best  width  is  half  an  inch.  It  is 
well  to  be  provided  with  three  osteotomes  of  the 
same  width,  but  of  different  thickness,  in  order  that, 
if  the  largest  gets  wedged,  it  may  be  withdrawn  and 
replaced  by  the  next  smaller,  to  be  again  replaced 
by  the  third  if  it  be  found  necessary.  I  also  have 
an  osteotome  of  the  same  shape,  but  only  one  quar- 
ter of  an  inch  wide,  for  section  of  the  fibula  or  any 
small  bone. 

Most  of  the  osteotomes  found  in  instrument- 
stores  are  not  made  properly.  They  have  a  bulge 
just  above  the  cutting  edge,  like  a  post-mortem 
chisel.  In  some  trials  made  upon  the  cadaver  with 
such  an  instrument  it  was  found  that  the  bone  was 
invariably  splintered  at  right  angles  to  the  line  of 
desired  section,  the  fracture  extending  several  inches 
above  or  below  the  instrument.  This  was  due  to  the 
thickness  of  the  chisel  just  above  its  cutting  edge 
acting  too  much  like  a  wedge.  The  force  required 
to  drive  such  an  instrument  into  the  bone  is  much 
greater  than  with  one  made  with  straighter  lines. 

An  instrument  properly  made  can  be  driven  into 
the  bone  without  turning  from  its  direction. 

The  mallet  should  be  made  heavier  than  those 
sold  in  necrosis  cases.  In  fact,  a  good-sized  carpen- 
ter's mallet  is  the  best.  A  sand  pillow,  about  six  by 
eight  inches  square  and  three  quarters  filled  with 
sand,  and  covered  over  with  rubber  cloth,  complete 
the  special  outfit. 


OSTEOTOMY.  19 

The  chisel  for  performing  a  cuneiform  osteotomy 
is  shaped  much  like  a  carpenter's;  half  an  inch  is 
sufficient  for  its  width.  It  should  taper  down  more 
than  the  common  necrosis  chisel,  and  the  beveled 
portion  should  not  be  too  large.  It  should  have  a 
temper  similar  to  the  osteotome. 

Osteotomy  is  either  linear  or  cuneiform.  The  for- 
mer is  performed  through  a  small  wound,  just  large 
enough  to  easily  admit  the  osteotome.  The  latter 
must  be  done  through  an  open  wound,  and  is  there- 
fore not  subcutaneous. 

The  limb  in  either  case,  if  possible,  should  be  ren- 
dered bloodless  by  the  use  of  an  Esmarch  bandage 
or  any  other  method,  as,  especially  in  cuneiform  sec- 
tions, it  renders  the  operation  much  easier  and  does 
away  with  the  constant  use  of  the  sponge. 

In  regard  to  the  use  of  Listerism,  I  am  clearly  of 
the  opinion  that  it  affords  no  additional  safety,  and 
I  have  long  since  abandoned  its  use.  The  method 
of  management  of  the  wound  will  be  given  in  detail 
farther  on. 

Simple  Osteotomy.  —  The  patient  having  been 
placed  thoroughly  under  the  influence  of  an  anaes- 
thetic, the  limb  rendered  bloodless  if  that  is  pos- 
sible, and  the  point  of  section  decided  upon,  an  in- 
cision is  made  with  a  sharp  scalpel  immediately 
down  to  the  bone.  Unless  there  are  special  reasons 
for  so  doing,  the  bone  should  not  be  reached  by  dis- 
secting down  to  it,  but  a  quick,  clean  cut  should  be 
made.  The  line  of  the  incision  should  be  parallel 
with  the  line  of  the  fiber  of  the  muscles  through 
which  the  wound  passes.  As  a  rule,  this  is  parallel 
with  the  long  axis  of  the  limb.     The  place  of  in- 


20  OSTEOTOMY. 

cision  should  be  so  planned  as  to  avoid  any  artery 
or  vein.  The  length  of  the  wound  should  be  only 
sufficient  to  easily  admit  the  osteotome.  This  in- 
strument is  then  passed  down  upon  the  knife  as  a 
guide,  and,  when  the  former  is  well  down  upon  the 
bone,  the  latter  is  withdrawn,  and  the  osteotome  is 
rotated  so  as  to  be  at  right  angles  with  the  long  axis 
of  the  bone,  and  then  driven  in  with  pretty  firm 
blows  with  the  mallet.  After  each  blow  the  in- 
strument is  moved  in  a  direction  at  right  angles  to 
the  long  axis  of  the  bone — that  is,  in  the  line  of  the 
axis  of  the  instrument — in  order  to  keep  it  from  be- 
coming wedged  and  to  change  the  direction  of  the  cut 
in  the  bone.  It  is  also  well,  in  bones  of  any  width, 
to  first  divide  the  bone  throughout  its  superficial 
surface,  and  then  gradually  to  work  from  without 
inward  through  its  width.  Under  no  circumstance 
should  the  osteotome  be  used  as  a  lever,  as  it  will 
result  in  breaking  the  instrument.  In  some  cases  the 
bone  may  be  divided  in  a  fan-shaped  manner  by 
working  in  different  directions  from  the  point  of 
first  entrance.  Divisions  should  be  commenced  with 
the  largest  osteotome,  if  the  bone  is  of  any  size,  as 
the  femur  or  tibia,  because  after  a  time  the  instru- 
ment becomes  wedged  and  is  difficult  to  work.  It 
can  then  be  withdrawn  and  replaced  by  the  next 
smaller,  this  to  be  again  replaced  by  the  third  if 
necessary.  Another  reason  is,  that,  by  using  the  lar- 
gest first,  the  cut  is  made  more  V-shaped.  When 
the  osteotome  has  penetrated  the  hard,  compact, 
bony  tissue  in  the  external  portion,  it  will  be  felt 
to  work  more  rapidly.  When  the  external  portion 
on  the  opposite  side  of  the  bone  is  reached,  it  will 


OSTEOTOMY.  21 

be  detected  by  the  resistance  in  cutting.  Then,  as 
Macewen  remarks,  the  osteotome  acts  as  a  probe  as 
well  as  cutting  instrument. 

During  section  the  wound  may  be  kept  damp 
with  carbolized  water,  but  I  do  not  think  it  essen- 
tial, nor  do  I  place  my  instruments  in  any  antiseptic 
solution  before  using.  When  the  bone  has  been 
nearly  divided,  the  osteotome  is  removed  and  the 
section  completed  by  fracturing  the  remaining  por- 
tion, a  sponge  wet  with  carbolized  water  being 
first  placed  over  the  wound  and  held  firmly  in  place 
to  prevent  the  entrance  of  air.  The  bone  should 
have  been  sufficiently  severed  to  make  the  fracture 
easy  without  the  use  of  much  force.  If,  however, 
it  can  not  be  broken  without  the  use  of  too  much 
force,  the  osteotome  is  re-entered  and  further  section 
made.  After  fracture,  the  sponge  is  firmly  secured 
over  the  wound  with  a  few  turns  of  a  bandage,  and 
then  the  Esmarch  bandage  removed.  The  limb  is 
then  left  while  the  same  operation  is  performed  upon 
the  other  side.  In  case  only  one  limb  is  to  be 
operated  upon,  it  is  well  to  let  the  parts  remain  at 
rest  for  a  few  moments  until  the  circulation  in  the 
limb  has  been  re-established.  The  haemorrhage  after 
an  osteotomy  is  slight.  I  have  never  seen  enough  to 
cause  any  anxiety,  although  in  a  few  cases  there 
may  be  quite  a  free  venous  haemorrhage  if  the 
sponge  has  been  removed  too  soon.  There  is,  more- 
over, more  blood  oozing  from  the  wound  when  the 
section  has  been  made  near  the  epiphysis  of  the 
tibia  or  when  the  bone  is  superficial.  In  deep 
osteotomies  the  blood  is  effused  among  the  muscles, 
and  does  not  come  out  of  the  wound  unless  pressed 


22  OSTEOTOMY. 

out.     I  have  once  divided  an  artery  of  some  size, 
to  which  reference  will  be  made  in  another  place. 

Management  of  the  Wound. — On  removing  the 
sponge  from  over  the  wound,  it  will  be  found  that 
the  haemorrhage  has  almost  ceased,  but  that  blood 
can  be  forced  up  from  its  deeper  portions,  or  will  con- 
tinue to  ooze  if  the  bone  be  superficial.  Macewen 
has  advised  that  any  piece  of  adipose  or  cellular 
tissue  that  may  protrude  from  between  the  lips  of 
the  wound  should  be  removed  with  a  pair  of  curved 
scissors,  as  it  will  prove  a  source  of  irritation  and 
prevent  the  closure  of  the  wound  by  a  blood-ciot. 
Experience  has  proved  that  this  is  an  important 
point,  and,  from  the  neglect  of  this,  failure  to  obtain 
rapid  closure  of  the  wound  is  almost  always  due. 
Macewen  dresses  the  wound  on  strict  Listerian  prin- 
ciples. I  do  not  think  that  there  is  any  gain  thereby. 
The  method  that  has  gained  excellent  results  is  as 
follows :  In  deep  wounds,  after  removing  any  piece 
of  tissue  from  between  the  lips  of  the  wound,  it  may 
be  washed  out  with  some  carbolized  water  of  the 
strength  of  1  to  40,  and,  after  the  parts  are  well  dried, 
a  strip  of  adhesive  plaster,  about  half  the  width  of 
the  length  of  the  wound,  and  long  enough  to  pass  one 
quarter  of  the  way  around  the  limb,  is  applied,  pass- 
ing over  the  center  of  the  wound,  care  being  taken 
to  bring  the  edges  of  the  incision  into  perfect  coap- 
tation. The  object  in  only  partially  covering  the 
incision  is  that,  if  there  is  any  undue  accumulation 
of  blood,  it  can  find  vent  through  the  portions  of  the 
wound  not  covered  by  the  plaster,  and  thus  prevent 
tension  of  the  parts.  The  limb  about  the  point  of 
operation  is  now  dusted  over  with  iodoform  diluted 


OSTEOTOMY.  23 

with  subnitrate  of  bismuth,  and  over  this  is  jxlaced 
a  small  compress  of  cheese-cloth,  two  or  three 
inches  square  and  four  or  five  layers  thick.  Or  a 
compress  of  Lister's  gauze  may  be  used.  If  it  is 
possible,  a  flannel  bandage  is  applied  from  the  ex- 
tremity to  some  distance  above  the  point  of  section, 
and  over  this  a  plaster-of-Paris  bandage  (we  are  con- 
sidering osteotomies  below  the  middle  of  the  thigh). 
Before  the  plaster  sets,  the  deformity  should  be  cor- 
rected and  held  in  the  proper  position  until  it  has 
well  hardened.  I  think  it  is  well  always  to  over- 
correct  a  little,  for,  as  the  bandage  becomes  loose, 
there  is  a  tendency  to  lose  a  little  of  the  correction. 
It  will  be  found  that,  by  the  addition  of  some  sul- 
phate of  potash  to  the  water  in  which  the  plaster-of- 
Paris  bandages  are  soaked,  they  will  harden  much 
more  rapidly. 

The  bandage  on  the  following  day  will  be  found 
more  or  less  stained  with  blood  from  the  oozing  that 
has  taken  place,  but  it  is  of  no  consequence,  and  needs 
no  attention.  On  the  third  day  a  fenestra  should  be 
cut  over  the  seat  of  the  wound,  the  compress  re- 
moved, and  the  wound  examined.  An  easy  way  to 
remove  a  small  window  is  to  make  two  cuts  with  a 
saw,  at  right  angles  to  the  long  axis  of  the  bone  and 
about  two  inches  apart,  through  the  plaster,  and  then 
to  unite  their  extremities  by  cuts  with  a  strong  knife. 
The  square  piece  can  then  be  lifted  out,  the  flannel 
bandage  cut,  and  through  this  opening  the  compress 
removed  and  the  wound  examined.  The  adhesive 
plaster  need  not  be  removed.  If  there  is  any  oozing 
from  the  cut,  a  fresh  piece  of  compress  should  be  ap- 
plied, and  the  wound  examined  every  day.  If  it  is 
3 


24  OSTEOTOMY. 

dry,  a  little  lint  may  be  placed  over  it,  and  no  fur- 
ther dressing  is  required. 

The  result  from  this  way  of  managing  wounds 
has  been  eminently  successful.  In  all  but  exceptional 
cases  the  incision  has  been  found  united  on  the  third 
day,  being  represented  by  a  mere  line.  Macewen's 
method  aims  at  union  by  means  of  an  organized  clot. 
Of  this  method  he  says : 1  "  During  the  first  twenty- 
four  hours  the  dressings  ought  to  be  looked  at,  in 
order  to  detect  any  appearance  of  blood-stains.  If 
a  stain  of  blood  shows  itself,  the  dressings  must  be 
removed.  If  there  is  no  blood-stain  during  the  first 
forty-eight  hours,  it  is  unlikely  that  any  will  after- 
ward appear.  .  .  .  The  dressings  are  put  on  (strict 
Lister)  in  the  operating-room,  and  not  touched,  unless 
blood  appears,  for  a  fortnight." 

Again,  on  page  175,  in  speaking  of  the  organiza- 
tion of  a  blood-clot,  he  says :  "  The  ordinary  course 
which  a  wound  healing  by  blood-clot  takes  may  be 
described  as  follows:  The  blood  is  effused  between 
the  lips  of  the  wound,  and  forms  a  clot.  During  the 
first  few  days  a  layer  of  translucent,  yellowish  mate- 
rial is  often  effused  from  the  surface  of  the  clot.  This, 
however,  is  not  constant.  During  the  first  week  the 
blood-clot  remains  soft  and  moist ;  then  it  becomes 
opaque  round  the  margins,  and  by  and  by  dries,  the 
opacity  and  dryness  gradually  extending  centripe- 
tally."  Closing  of  a  wound  by  a  blood-clot  takes 
ten  or  twelve  days;  by  primary  union,  two  or  three 
days. 

With  care  to  remove  everything  that  may  pro- 
trude from  between  the  lips   of  the  wound,  primary 

1  "  Osteotomy,"  he.  cit. 


OSTEOTOMY.  25 

union  should  be  obtained  in  all  cases.  The  simpli- 
city with  which  the  plan  advocated  in  these  pages 
can  be  carried  out  is  in  contrast  to  that  of  Mace  wen. 
Since  adopting  this  method,  I  have  performed  over 
sixty  linear  osteotomies.  In  all  but  three  cases  the 
wound  was  united  on  the  third  day.  Failure  to  ob- 
tain primary  union  was  in  two  cases  due  to  the  fact 
that  the  wound  was  not  properly  cared  for.  In  the 
third  no  reason  can  be  assigned. 

It  is  evident  that  the  earlier  the  wound  closes  the 
less  is  the  liability  of  any  accident,  and  the  closer 
will  the  reparative  process  in  the  bone  follow  the 
course  of  a  simple  fracture.  I  believe  that  the  suc- 
cess of  an  osteotomy  depends  more  upon  the  man- 
agement of  the  small  incision  than  upon  any  detail 
in  the  section  of  the  bone,  and  that  the  neglect  to 
remove  any  tissue  that  protrudes  between  the  lips  of 
the  incision  is  the  cause  above  all  others  of  suppura- 
tion. 

The  temperature  after  an  osteotomy  seldom  rises 
above  100°  R,  and  in  the  majority  of  cases  does 
not  get  above  normal.  In  a  few  patients  I  have 
seen  a  temperature  of  102°  or  103°  F.  without  any 
assignable  cause,  the  wound  pursuing  a  perfectly 
normal  course.  As  a  rule,  however,  a  registration  of 
the  mercury  above  100°  after  the  third  day  demands 
a  careful  inspection  of  the  wound,  as  it  may  denote 
suppuration.  The  temperature  in  children  often 
rises  rapidly,  and  has  as  sudden  fall  without  any 
serious  import.  A  temperature  of  103°  the  day  after 
an  osteotomy  in  an  excitable  child  has  been  met 
with,  yet  the  wound,  on  inspection,  appeared  perfect- 
ly normal,  and  primary  union  was  obtained.     Again, 


26  OSTEOTOMY. 

I  Lave  seen  quite  a  large  abscess  in  the  soft  parts,  of 
which  the  thermometer  gave  not  the  slightest  indi- 
cation. So  the  thermometer  is  not  an  infallible 
guide  as  to  the  presence  of  pus. 

The  pain  after  an  osteotomy  is  generally  slight.  I 
have  seen  a  child,  two  hours  after  an  osteotomy  of 
both  tibia,  sitting  up  in  bed  and  playing  with  her  toys 
as  though  nothing  had  been  done.  But,  as  a  rule,  a 
small  dose  of  some  anodyne  is  required  the  first  night. 

The  first  dressing  (plaster  splint)  can  usually  be 
left  on  until  firm  union  has  taken  place  and  the  pa- 
tient is  well  enough  to  be  up  and  about. 

Cuneiform  Osteotomy. — In  anterior  curvatures  of 
the  tibia,  and  in  angular  deformities  of  the  long 
bones,  a  wedge  of  bone  has  often  to  be  removed. 
For  this  purpose  a  chisel,  and  not  an  osteotome,  is 
used,  and  the  operation  is  through  an  open  wound. 

An  Esmarch  bandage  having  been  applied,  an  in- 
cision is  made  parallel  to  the  long  axis  of  the  limb, 
directly  down  to  the  bone  at  the  point  of  greatest 
curvature,  long  enough  to  give  plenty  of  room, 
which  will  be  found,  in  the  deepest  portion  of  the 
wound,  to  be  a  little  longer  than  the  width  of  the 
wedge  to  be  removed.  If  the  bone  is  covered  with 
much  muscular  tissue,  the  incision  in  the  skin  will 
have  to  be  somewhat  longer.  The  periosteum  is  di- 
vided in  the  same  line  as  the  incision  in  the  soft 
parts,  and  is  of  the  same  length.  Another  short  in- 
cision at  right  angles  to  the  first  at  about  its  middle 
is  often  an  advantage.  The  periosteum  is  then  sepa- 
rated from  the  bone  well  down  on  either  side.  The 
exact  size  of  the  wedge  to  be  removed  should  be  ac- 
curately ascertained  before  beginning  the  operation. 


OSTEOTOMY. 


27 


A  ready  way  is  to  take  a  narrow  piece  of  lead  and 
mold  it  to  the  curvature  of  the  bone.  This  can  be 
traced  upon  a  piece  of  paper  or  card-board,  and  a 
line  drawn  parallel  to  it  at  a  distance  equal  to  the 
thickness  of  the  bone.  By  cutting  this  out  you  have 
a  pattern  of  the  outline  of  the  bone.  Now  cut  this 
in  two  at  the  point  of  greatest  curvature,  and,  by 
placing  one  piece  over  the  other  until  the  line  of  the 
upper  border  is  straight,  the  amount  that  one  over- 
laps the  other  will  represent  the  size  of  the  wedge  to 
be  removed. 


Fig.  5. 


Fig.  6. 


Figs.  5  and  6  are  reduced  from  the  pattern  of  a 
case  of  anterior  curvature  of  the  tibia.  Fig.  5  shows 
the  amount  of  deformity,  and  the  dotted  lines  in 
Fig.  6  the  size  of  the  wedge  of  bone  to  be  removed, 
in  order  to  correct  the  deformity. 

In  the  beginning  a  much  smaller  wedge  should 
be  removed  than  is  required,  by  cutting  with  the 
flat  side  of  the  chisel  toward  the  part  of  the  bone  to 
be  left.  This  can  be  increased  by  chips  or  shavings 
removed  alternately  from  either  side,  and  gradually 
increasing  in  depth.  By  keeping  the  chisel  inside  of 
the  periosteum,  there  will  be  no  danger  of  injuring 


28  OSTEOTOMY. 

the  soft  parts  on  either  side  of  the  bone.  The  apex 
of  the  wedge  should  extend  well  into  the  compact 
tissue  on  the  opposite  side  of  the  bone.  When  this 
point  has  been  reached  and  the  whole  width  of  the 
bone  included  in  the  wedge,  the  section  can  be  com- 
pleted by  driving  an  osteotome  directly  backward 
from  the  apex  of  the  cuneiform  section.  If  the  V- 
shaped  piece  has  been  accurately  calculated,  the  two 
opposite  surfaces  will  come  into  apposition,  and  the 
deformity  just  corrected.  During  the  operation,  care 
should  be  taken  to  remove  all  the  shavings  of  bone. 
A  sponge  wet  with  carbolized  water  is  placed  over 
the  wound  and  the  Esmarch  bandage  removed.  The 
haemorrhage  from  a  cuneiform  is  much  greater  than 
that  from  a  linear  osteotomy.  After  the  circulation 
has  become  re-established  in  the  limb  the  sponge  is 
removed,  and  any  vessel  that  may  cause  trouble  se- 
cured with  carbolized  gut.  The  edges  of  the  perios- 
teum are  to  be  approximated  with  antiseptic  liga- 
tures. If  the  bone  is  subcutaneous,  and  if  it  is  pos- 
sible, a  counter-opening  should  be  made  opposite  the 
apex  of  the  wedge,  and  carbolized  horse-hair  passed 
from  this  through  the  operation  wound.  The  lips  of 
the  wound  should  then  be  brought  into  perfect  co- 
aptation with  carbolized  gut,  the  horse-hair  being 
brought  out  at  one  corner.  Over  the  line  of  inci- 
sion iodoform  is  dusted,  and  then  a  small  compress 
applied  sufficient  to  cover  the  wound,  and  over  this 
again  a  flannel  bandage  and  plaster-of-Paris  splint, 
if  in  a  position  where  such  a  dressing  is  applicable. 
On  the  second  day  a  fenestra  is  to  be  cut,  the  com- 
press removed,  and  the  horse-hair  is  taken  out  piece 
by  piece.     This  is  easily  done  without  giving  the 


OSTEOTOMY.  20 

patient  any  pain.  A  fresh  compress  is  applied,  and 
over  this  a  bandage  to  keep  it  in  place. 

The  reason  why  a  counter-opening  is  advocated  is 
because  in  a  certain  class  of  cases,  where  the  bone  is 
superficial,  on  account  of  the  increased  amount  of 
haemorrhage  there  is  liable  to  be  too  much  tension  of 
the  skin,  thus  preventing  primary  union.  Before  I 
adopted  this  plan  I  invariably  had  suppuration,  but 
since  its  adoption  have  secured  primary  union  in 
every  case. 

In  correcting  after  a  cuneiform  osteotomy  great 
care  should  be  taken  that  no  portion  of  tissue  gets 
between  the  ends  of  the  bone.  Should  such  an  acci- 
dent happen,  suppuration  will  be  sure  to  follow. 
I  think  that  many  cases  of  suppuration  after  this 
operation  are  due  to  this  accident. 

An  argument  has  been  frequently  used  against 
osteotomies,  that  in  performing  them  compound  frac- 
tures are  produced,  and  as  compound  fractures  are 
exceedingly  dangerous,  therefore  osteotomies  are  ex- 
ceedingly dangerous  operations.  In  only  one  respect 
can  an  osteotomy  be  classed  with  a  compound  frac- 
ture, and  that  is  that  in  both  there  is  a  communica- 
tion between  the  ends  of  the  bone  and  the  air;  but 
the  bone  is  reached  in  the  former  by  a  clean-cut  wound 
without  any  disturbance  of  the  soft  parts ;  in  the  lat- 
ter the  wound  is  a  contused  and  lacerated  one,  caused 
either  by  the  ends  of  the  fractured  bone,  or  by  the 
violence  causing  the  injury.  The  danger  from  a  com- 
pound fracture  is  not  the  simple  fact  that  there  is  a 
communication  with  the  bone,  but  that  the  soft  parts 
are  torn  and  lacerated,  and  herein  arises  the  danger. 
Osteotomy  should  be  classed  as  simple  fracture. 


CHAPTEE  III. 

OSTEOTOMY  FOR  DEFORMITIES  AT  THE  HIP  JOINT. 

Deformities  at  the  hip  joint  which  may  be  re- 
lieved by  an  osteotomy  may  be  considered  under 
four  heads,  namely : 

1.  After  hip-joint  disease. 

2.  After  rheumatism. 

3.  After  unreduced  dislocation. 

4.  After  fractures  united  at  an  angle. 

The  great  majority  of  deformities  of  this  joint  fol- 
low coxalgia.  There  are  but  few  persons  who  have 
had  suppurative  disease  of  this  articulation  who  re- 
cover with  motion,  and  many  in  whom  there  have 
been  no  signs  of  abscess,  yet  the  joint  remains  stiff, 
with  an  amount  of  flexion  and  adduction  which  in- 
terferes much  with  locomotion.  Or  there  may  be 
some  movement,  yet,  on  account  of  the  contraction  of 
the  psoas  and  iliacus,  and  the  adductors,  the  limb  is 
flexed  and  adducted  on  the  pelvis  at  an  angle  too 
great  for  easy  locomotion.  The  foot  can  not  be 
planted  firmly  on  the  ground  even  with  the  greatest 
latitude  of  motion  at  the  lower  lumbar  vertebrae,  the 
gait  being  awkward  and  labored.  It  becomes  a  ques- 
tion whether  by  an  operation  any  improvement  can 
be  obtained. 


DEFORMITIES  AT  THE  HIP  JOINT.  31 

An  anchylosed  Lip  joint,  in  which  the  limb  is 
held  in  a  perfectly  straight  line  with  the  long  axis  of 
the  body,  is  a  useful  one  for  walking  or  standing, 
but  is  more  of  a  deformity  in  any  other  position  of 
the  body  than  one  fixed  at  a  right  angle  to  the  pelvis. 
In  the  former  case  the  person  can  not  sit  down  with 
any  degree  of  comfort,  or  put  on  his  shoes,  whereas 
in  the  latter,  by  the  aid  of  proper  orthopedic  appli- 
ances, not  only  is  the  sitting  posture  comfortable,  but 
locomotion  can  be  performed  with  considerable  facili- 
ty. It  therefore  becomes  an  interesting  question  at 
what  angle  an  anchylosed  hip  should  be  placed  so 
as  to  be  a  compromise,  as  it  were,  between  the  two 
positions,  and  give  the  patient  the  greatest  amount 
of  use  ;  that  is,  easy  walking  and  comfort  in  the  sit- 
ting posture.  I  think  that  an  angle  of  125°  with  the 
transverse  axis  of  the  pelvis  when  in  an  erect  posi- 
tion gives  this.  It  permits  of  comfortable  locomo- 
tion, ease  in  sitting,  and  ability  to  put  on  his  shoes. 
This,  then,  taken  as  a  standard,  enables  us  to  dis- 
cuss the  question  of  correcting  any  marked  deviation 
on  either  side  of  this  line.  The  angle  of  deviation 
is  obtained  by  standing  the  patient  erect  and  bring- 
ing up  the  thigh  until  the  lordosis  is  obliterated,  or, 
in  other  words,  until  the  pelvis  assumes  its  normal 
position. 

The  deformity  after  hip-joint  disease  is  due,  first, 
to  contraction  of  the  psoas  and  iliacus  muscles,  caus- 
ing flexion  and  rotation  of  the  limb  ;  second,  to  the 
action  of  the  adductors,  drawing  the  thigh  toward 
the  median  line.  This  is  accompanied  or  followed 
by  tilting  of  the  pelvis  upward  on  the  diseased  side 
in  order  to  bring  the  limb  more  in  a  line  with  the 


32  OSTEOTOMY. 

long  axis  of  the  body,  and  thus  prevent  it  from  cross- 
ing over  the  sound  one.  It  is  a  compensatory,  not 
pathological,  position.  In  the  early  stage  of  this  af- 
fection the  apparent  shortening  is  due  to  this  tilt- 
ing of  the  pelvis.  Later,  in  those  cases  in  which 
changes  take  place  in  the  head  and  acetabulum,  there 
is  actual  shortening  of  the  limb. 

The  absorption  more  or  less  of  the  head  of  the 
femur,  and  the  higher  plane  occupied  by  the  trochan- 
ter, due  partly  to  the  above-mentioned  change  and 
partly  to  elongation  of  the  acetabulum  in  its  upper 
or  posterior  diameter,  increases  in  no  small  degree 
the  deformity  and  the  amount  of  shortening  of  the 
limb. 

The  difficulty  in  walking  is  not  due  so  much  to 
the  shortening  and  flexion  as  to  the  adduction  of  the 
limb,  whether  the  anchylosis  be  bony  or  fibrous. 
The  characteristic  awkward  gait  of  a  patient  who 
has  recovered  from  a  coxalgia  with  anchylosis  is  due 
to  the  tilting  upward  of  the  pelvis  on  the  diseased 
side.  In  time  other  muscles  become  shortened,  and 
add  another  element  to  the  problem  of  correction. 

The  muscles  chiefly  at  fault  are  the  psoas  and 
iliacus,  and  the  adductors;  and,  even  when  the  de- 
formity is  corrected  by  any  operation  above  the  in- 
sertion of  the  former,  the  question  still  remains,  How 
can  we  elongate  them  ?  From  their  origin  and  inser- 
tion being  movable,  it  is  impossible  to  apply  any 
force  in  order  to  lengthen  them.  When  extension  is 
applied  to  the  thigh  the  lumbar  vertebrse,  arch  for- 
ward (lordosis),  and  when  the  lordosis  is  obliterated 
the  thigh  is  flexed  more  or  less,  being  carried  forward 
by  the  pelvis. 


DEFORMITIES  A  T  THE  HIP  JOINT.  33 

In  those  cases  in  which  anchylosis  does  not  take 
place  there  may  be  motion  in  the  direction  of  far- 
ther flexion,  but  extension  beyond  a  certain  point  is 
impossible ;  and,  although  the  thigh  can  be  brought 
down  so  that  the  foot  can  be  planted  flat  on  the 
ground,  it  is  not  from  further  extension,  but  is  ac- 
complished by  bending  inward  of  the  lumber  spine, 
due  to  the  same  shortening  of  the  muscles  inserted 
into  the  trochanter  minor.  In  this  class  of  cases 
walking  is  almost  as  difficult  as  in  those  where  the 
joint  is  fixed. 

In  cases  where  suppuration  has  been  extensive 
the  soft  parts  about  the  region  of  the  hip  joint  are 
often  infiltrated  with  cicatricial  tissue  which  binds 
the  skin  to  the  bone. 

In  anchylosis  following  rheumatic  inflammation 
the  condition  of  the  parts  is  entirely  different ;  the 
head  and  neck  are  intact,  the  bone  is  not  infiltrated 
with  inflammatory  products  of  low  vitality.  It  may 
be  increased  in  hardness,  but  the  parts  retain  their 
normal  relations,  the  neck  is  not  shortened,  the  an- 
chylosis is  usually  bony,  the  soft  parts  are  normal, 
and  the  psoas  and  iliacus  are  not  as  much  of  an  ele- 
ment in  causing  the  deformity.  It  is  clue  more  to 
position,  while  in  hip-joint  disease  it  is  the  active 
contraction  of  the  muscles  that  causes  the  deformity. 
In  this  disease  the  limb  may  be  fixed  in  a  straight 
line  with  the  body,  a  condition  very  seldom,  if  ever, 
met  with  after  coxalgia. 

In  rheumatoid  arthritis  the  joint  may  be  sur- 
rounded by  irregular  bony  growth,  while  the  bone 
itself  is  very  compact  and  hard,  like  ivory. 

Deformities  due  to  unreduced  dislocations  are  not 


34  OSTEOTOMY. 

of  frequent  occurrence.  The  dislocation  may  be  trau- 
matic, or  pathological. 

The  latter  may  occur  during  the  course  of  hip- 
joint  disease,  but  I  do  not  think  that  they  are  as 
common  as  some  writers  would  lead  us  to  suppose. 
It  may  occur  during  the  course  of  some  debilitating 
disease,  as  typhoid  fever.1  I  have  seen  one  taking 
place  upon  the  dorsum  of  the  ilium  during  an  at 
tack  of  acute  polyarticular  rheumatism,  complicated 
with  serious  heart  trouble.  Burns 2  reports  a  simi- 
lar case.  In  cases  of  dislocation  in  hip-joint  disease 
the  head  is  often  found  much  altered. 

Malpositions  of  the  femur  after  fracture  are  some- 
times met  with,  and  should  be  included  in  this  class. 

In  all  of  these  cases  (fracture  of  the  femur  ex- 
cluded, unless  they  occur  very  high  up)  one  of  the 
chief  obstacles  to  the  correction  of  the  deformity  and 
causing  the  difficulty  in  walking  is  the  contraction 
of  the  adductors.  Flexion  alone  is  not  the  chief 
cause  of  the  trouble.  It  is  the  adduction  of  the 
limb ;  and,  even  if  the  dislocation  is  reduced,  the 
muscles  carry  the  limb  inward,  and  must  be  cut  in 
order  to  afford  relief. 

There  is  a  well-grounded  opinion  among  practical 
surgeons  that  any  attempt  to  correct  deformities  at 
the  hip  joint  after  suppurative  coxalgia,  or  to  regain 
motion  in  this  articulation,  should  not  be  entertained. 
My  own  experience  has  been  anything  but  encourag- 
ing. Two  cases  in  which  I  made  the  attempt  resulted 
in  rekindling  a  disease  in  the  joints  that  had  shown 
no  symptom  for  several  years,  and  which,  in  one, 
ended  in  the  death  of  the  patient. 

1  Rawdon, "  Liverpool  Med.-Chir.  Jour.,"  1882,  p.  22.    2  "  Centralbl.,"  18*79,  p.  691. 


DEFORMITIES  AT  THE  EIP  JOINT.  35 

Morton,  of  Philadelphia,  has  had  a  similar  unfor- 
tunate experience. 

The  records  of  many  hospital  surgeons  show  simi- 
lar results.  It  is  true  that  in  a  few  cases  the  opera- 
tion of  forcibly  straightening  has  been  followed  by 
success.  Gay  reported  such  a  case  at  the  meeting  of 
the  American  Medical  Association,  1882,  in  which 
the  neck  was  fractured  and  an  improved  position 
obtained.  Mr.  Broadhurst '  also  advocates  forcible 
straightening,  and  claims  remarkable  success.  But 
the  cases  are  so  carelessly  reported  that  it  is  impos- 
sible to  form  any  opinion  of  the  results.  I  am  decid- 
edly of  the  opinion  that  under  no  circumstances 
should  a  hip  joint  that  has  been  the  seat  of  sup- 
purative coxalgia  be  forcibly  straightened.  It  is  a 
dangerous  operation,  and  is  unwarrantable. 

The  position  of  the  trochanter  on  the  diseased  side 
may  be  taken  as  an  index  of  the  amount  of  alteration 
in  the  head  and  neck  of  the  femur.  If  it  is  hio;her 
than  on  the  sound  side,  the  position  of  the  foot  being 
normal,  the  change  must  be  due,  in  the  vast  majori- 
ty of  cases,  to  absorption  of  the  head  and  neck ;  and 
the  more  the  upper  border  of  the  trochanter  major 
is  above  Nelaton's  line,  the  more  profound  must 
be  the  alteration  in  the  upper  part  of  the  femur. 
Shortening  of  the  limb,  that  is,  the  measurement 
from  the  anterior-superior  spine  of  the  ilium  to  the 
internal  malleolus  is  not  as  reliable  a  guide  as  to  the 
condition  of  the  neck  as  the  position  of  the  trochan- 
ter, because  the  whole  limb  may  be  atrophied  from 
disease  without  any  marked  change  in  the  neck. 

1  "On  Anchylosis,"  London,  1881. 


36  OSTEOTOMY. 

Histoey. — In  1826,  Rhea  Barton1  devised  and 
carried  out  the  following  operation  for  anchylosis 
of  the  hip  joint  at  a  right  angle  subsequent  to  in- 
flammation of  that  articulation :  The  patient  was 
a  sailor  twenty-one  years  of  age.  The  limb  was 
flexed  at  a  right  angle,  rotated  inward,  and  ad- 
ducted.  A  straight  incision  was  made  parallel  to 
the  long  axis  of  the  limb  at  the  upper  portion  of  the 
thigh,  and  a  short  transverse  one  at  the  point  of  in- 
tended section.  The  bone  was  divided  with  a  nar- 
row saw  just  above  the  trochanter  minor.  No  ves- 
sels were  ligated.  Primary  union  was  not  desired. 
The  operation  was  completed  in  seven  minutes. 
Passive  motion  was  commenced  on  the  twentieth 
day,  and  repeated  at  intervals  of  several  days.  At 
the  time  of  discharge,  two  months  after  the  opera- 
tion, the  patient  was  able  to  execute  "  every  move- 
ment which  the  limb  originally  possessed."  He  had 
a  movable  joint  for  six  years,  when  he  became  dissi- 
pated, the  new  joint  gradually  became  stiff,  and  at 
post-mortem  examination  the  artificial  joint  was 
found  anchylosed.2 

Rodger,3  in  1830,  removed  a  wedge-shaped  piece 
of  bone  above  the  trochanter  minor  from  a  man  forty- 
seven  years  of  age,  for  anchylosis  of  the  hip  joint,  at 
a  right  angle,  with  marked  adduction.  Clemot,4  in 
1834,  removed  a  wedge-shaped  piece  from  the  femur 
of  a  child  four  years  of  age  for  a  deformity  follow- 
ing hip-joint  disease. 

1  "  North  Am.  Med.  and  Surg.  Jour.,"  1827,  vol.  iii,  p.  279. 

2  "  Am.  Jour.  Med.  Sci.,"  1837,  vol.  xxi,  p.  333. 

3  "  N.  Y.  Jour.  Med.  and  Surg.,"  1840,  p.  240. 

4  "Gaz.  Med.  de  Paris,"  1836,  p.  347. 


DEFORMITIES  AT  TEE  HIP  JOINT.  37 

Maisonneuve '  made  a  section  between  the  tro- 
chanters. 

Mayer  first  proposed  an  osteotomy  for  old  dislo- 
cation, and  Broadhurst,  in  1862,  divided  the  neck  of 
the  femur  for  anchylosis  with  deformity  following 
hip-joint  disease.2  All  of  these  operations  were  made 
through  an  open  wound,  and  the  section  made  with 
a  saw. 

In  1862  Dr.  Lewis  A.  Sayre 3  made  a  section  of  the 
femur  just  above  the  trochanter  minor  and  removed  a 
"  semicircular  piece  of  bone  with  its  concavity  down- 
ward" and  rounded  off  the  upper  portion  of  the 
lower  fragment  so  as  to  be  received  into  this  cup- 
shaped  depression,  and  thus  aid  in  establishing  an' 
artificial  joint.  The  first  patient  operated  upon  in 
this  manner  is  reported  "  cured "  with  a  movable 
joint  at  the  point  of  operation.  He  repeated  the 
same  operation  later  upon  another  patient,  but  she 
died  of  tuberculosis  before  a  sufficient  time  had 
elapsed  to  establish  good  and  useful  motion.  In 
both  of  these  cases  there  was  necrosis  of  a  portion  of 
the  bone :  in  the  first,  two  pieces  that  "  seem  to  be 
exfoliated  from  the  lower  fragment "  :  in  the  second, 
"two  pieces  about  the  size  of  a  pin's  head."  In  the 
last  case,  at  post-mortem  examination  the  structures 
of  a  new  joint  are  reported  to  have  been  found.  (Fig. 
7  shows  the  line  of  Sayre's  section.) 

Walter4  repeated  Sayre's  operation  for  anchylosis 
of  both  hip  joints.    After  considerable  suppuration, 

1  "Gaz.  Med.  de  Paris,"  184V,  p.  935. 

2  "  Lancet,"  1862,  vol.  i,  p.  326. 

8  "  N.  Y.  Med.  Jour.,"  January,  1869,  p.  337. 
4  "Arch.  Clin.  Surg.,"  August,  18*76,  p.  60. 


38 


OSTEOTOMY. 


the  patient  is  reported  as  having  only  limited  motion 
at  the  new  articulation,  with  a  history  of  a  tendency 
to  become  stiff. 

In  1863  Weinlechner  performed  a  section  through 
the  neck  with  a  chisel.     Langen- 
beck,  in  1852,  corrected  deform- 
ities in  the  hip  joint  by  divid- 
ing the  bone  with  a  narrow  saw, 
passed  into  the  bone  through  a 
small  perforation   made  with  a 
drill.     Suppuration  followed  in 
all  the  cases  operated  on.      Mr. 
Adams,   in    1869,   first    divided 
the  neck  of  the  femur  through 
a  small  wound,  and  gave  to  the 
operation  the  name  of  subcuta- 
neous   osteotomy.      Since    that 
date  sections   of  the   femur  for 
deformity  have  been  performed 
by  surgeons  both  on  the  conti- 
nent and  in  this  country. 
Volkmann1  removed   a   wedge-shaped   piece   of 
bone   from  below  the  trochanter  major  in  order  to 
correct  the  adduction  in  bony  anchylosis  (Fig.  8). 
Later 2  he  substituted  an  excision  of  the  joint  with 
a  chisel  and  gouge,  a  linear  osteotomy  being  first 
performed,  and  then  the  head  and  neck  removed  in 
small  pieces.     He  reports  six  patients  operated  upon 
with  good  results  in  regard  to  the  re-establishment 
at  the  new  articulation. 

The  three  points  at  which  section  has  been  made 

1  "  Centralbl.  fur  Chirurg.,"  1874.  No.  1,  p.  1. 

2  "  Centralbl.  fiir  Chirurg.,  1880,  No.  5. 


Fig.  7. — Sayre's  line  of  sec- 
tion. 


DEFORMITIES  AT  THE  HIP  JOINT. 


39 


on  the  femur  are    through  the   neck,  between   the 
trochanters,  and  below  the  trochanter  minor. 

Maisonneuve,  in  1847,  divided  the  neck  of  the 
femur  through  an  open  wound,1  and  Weinlechner 
in  1863.  But  to  Mr.  Adams  is 
due  the  credit  of  devising  an  ope- 
ration through  a  very  small  wound 
and  reducing  the  risks  of  suppu- 
ration to  a  minimum.  The  instru- 
ments used  were  a  long  tenotomy- 
knife  and  a  very  small  saw* (Fig. 
1),  three  eighths  of  an  inch  wide, 
with  a  cutting  edge  one  inch  and 
a  half  in  length,  at  the  end  of  a 
slender  shank  three  inches  long. 
The  details  of  the  operation  are 
as  follows :  The  tenotomy-knife 
is  entered  a  little  above  the  top 
of  the  great  trochanter  and  car- 
ried straight  down  to  the  neck  of  the  thigh-bone. 
The  muscles  are  divided  and  the  capsular  ligament 
freely  opened.  Withdrawing  the  knife,  the  small 
saw  is  carried  along  the  track  made  straight  down 
to  the  bone,  which  is  then  divided  from  before 
backward,  and  at  right  angles  to  the  long  axis  of 
the  neck. 

After  the  division  is  completed  (Fig.  9),  those 
muscles  that  prevent  the  limb  being  brought  into 
the  desired  position  are  divided  and  the  limb  put  up 
in  a  straight  position.  He  simply  covers  the  wound 
with  a  compress  held  in  position  by  a  piece  of  ad- 
hesive plaster. 

1  "  Gaz.  de  Hop.,"  1849,  p.  64. 


Fig.  8. — Volkmann's  line 
of  section. 


40 


OSTEOTOMY. 


Goldino-.Bird  substituted  a  chisel  for  the  saw.1 
Stokes 2  divided  the  neck  with  an  osteotome  in 
Adams's  line. 

Operations  between  the  trochanters  have  been 
performed  by  Barton  and  Maisonneuve  and  Sayre 
through  an  open  wound,  division  of  the  bone  being 
made  with  a  saw.  Later,  sections  have  been  made 
through  a  small  wound  with  the  osteotome.  But  few 
cases  have  been  reported.  The 
operation  is  performed  like  any 
simple  osteotomy.  Cuneiform 
section  between  the  trochanters 
has  been  more  frequently  per- 
formed. They  seem  to  be 
adapted  to  those  cases  of 
marked  adduction. 

Mr.  Barwell3  divided  the 
femur  just  above  the  trochanter 
minor  with  a  chain-saw,  and  a 
strict  antiseptic  method,  argu- 
ing that  a  section  below  the 
trochanter  minor  would  pro- 
duce too  much  shortening, 
equal  in  amount  to  the  distance 
from  the  head  to  the  point  below  the  trochanter — 
from  two  to  three  inches.  The  wound  healed  by 
first  intention;  a  firm  union  was  established  in 
thirty-three  days. 

Mr.  Gant 4  made  a  section  with  an  osteotome  of 


Fig.  9. — Adams's  line  of 
section. 


1  "  Guy's  Hospital  Report,"  187V,  p.  278. 

2  "  Brit.  Med.  Jour.,"  April  8,  1882,  p.  505. 

3  "Brit.  Med.  Jour.,"  May  29,  1880,  p.  812. 

4  "  Lancet,"  December,  1872,  p.  881. 


DEFORMITIES  A  T  THE  HIP  JOINT. 


41 


the  shaft  of  the  femur  below  the  trochanter  minor 
for  deformity  at  the  hip  joint  (Fig.  10).  He  advo- 
cated it  for  anatomical  reasons :  that  the  resistance 
of  the  psoas  and  iliacus  was  set  free,  and  on  the 
pathological  grounds  in  that  the  section  was  made 
through  healthy  bone,  or  rather  at  a  greater  dis- 
tance from  the  point  of  disease  after  coxalgia,  and 
thus  the  operation  was  not  as 
liable  to  rekindle  the  joint 
trouble. 

Lately,  Dr.  Stephen  Smith1 
performed  the  following  opera- 
tion for  anchylosis  of  the  hip- 
joint  at  a  right  angle :  With  a 
Shrady's  saw  he  made  two  par- 
tial sections  of  the  femur  just 
below  the  trochanter  minor — 
one  from  its  posterior  and  one 
from  its  anterior  aspect  —  half 
an  inch  apart,  and  then  fractur- 
ing the  intervening  portion  of 
bone,  thus  making  a  half  tenon  Fig.  10.— Gant'siineofsec- 
and  mortise,  the  object  being 
to  prevent  any  tendency  to  displacement  of  lower 
fragment  so  as  to  endanger  non-union.  After  placing 
the  bone  in  position,  the  two  fragments  would  as- 
sume the  relations  exhibited  in  Fig-.  11. 

The  patient  recovered  after  evacuation  of  a  large 
abscess,  extending  from  the  point  of  operation  nearly 
down  to  the  knee. 

Adams's  operation  can  only  be  performed  when 
the  neck  of  the  bone  is  present.     It  is  therefore  only 

1  "Med.  Record,"  Jnne  2,  1883,  p.  589. 


42 


OSTEOTOMY. 


applicable  to  cases  of  anchylosis  following  rheuma- 
tism, and  possibly  those  cases  of  recovery  from  hip 
joint  disease  in  which  there  has 
been  but  slight  destruction  of 
these  parts  with  bony  anchylo- 
sis. But  it  is  a  serious  question 
whether  cases  of  deformity  after 
suppurative  coxalgia  should  ever 
be  submitted  to  the  operation. 
In  the  vast  majority  of  cases  the 
section  would  be  through  bone 
infiltrated  with  inflammatory 
products  of  low  vitality.  The 
incision,  to  gain  access  to  the 
neck,  would  frequently  have  to 
be  made  through  tissue  that  had 
been  riddled  with  abscesses,  and 
with  the  skin  often  bound  down 
to  the  bone,  and  even  after  a  sec- 
tion it  would  be  very  difficult  to 
bring  the  limb  down.  Adams's 
operation  is  not  applicable  to 
cases  where  the  psoas  and  the 
iliacus  are  greatly  shortened,  and 
this  occurs  more  often  after  hip- 
joint  disease  than  after  anchylosis 
following  any  other  condition. 

Cases  of  unreduced  traumatic 
dislocation  offer  a  much  better 
chance.  In  regard  to  the  class  of 
cases  that  are  suited  to  the  operation,  Mr.  Adams 
justly  states  "  that  those  cases  are  best  adapted  to  this 
operation  in  which  there  is  but  slight  destruction  of 


Fig.  11.  — Smith's  line  of 
section. 


DEFORMITIES  A  T  THE  HIP  JOINT.  43 

the  head  and  neck,  and  in  which  there  is  bony  an- 
chylosis, and  that  cases  of  anchylosis  after  rheumatic 
inflammation  are  the  most  favorable ;  those  after  sup- 
purative coxalgia  the  least  so." 

In  regard  to  operations  between  the  trochanters 
the  section  is  made  farther  away  from  the  seat  of 
disease  in  cases  of  deformity  after  suppurative  coxal- 
gia, and  it  also  permits  of  a  wedge-shaped  piece  of 
bone  to  be  removed,  if  so  desired,  in  cases  of  marked 
adduction.  Yet,  as  the  point  of  division  is  above  the 
insertion  of  the  psoas  and  iliacus,  there  is  a  doubt 
whether  the  deformity  is  as  easily  overcome  as  in 
section  below  that  point.  If  the  object  of  an  opera- 
tion is  to  obtain  useful  motion  in  addition  to  the 
correction  of  the  deformity,  there  is  no  question  but 
that  the  nearer  the  division  is  made  to  the  true  axis 
of  motion  the  better.  But  useful  motion  after  an 
osteotomy,  be  it  linear,  cuneiform,  or  elliptic,  is  rarely 
obtained,  no  matter  where  the  section  is  made.  Mo- 
tion has  been  obtained  in  some  cases,  but  they  are 
exceptional  I  do  not  think  that  an  inter- trochan- 
teric operation  is  the  best  for  deformity  after  joint 
disease.  It  is  too  near  the  point  of  old  disease,  and 
it  does  not  free  the  muscles  inserted  into  the  trochan- 
ter minor.  It  is,  however,  a  good  operation  vvhen 
the  bone  is  healthy ;  the  operation  below  the  trochan- 
ter minor  is  the  one  to  perform  after  hip-joint  dis- 
ease. Mr.  Gant  *  thus  very  concisely  states  the  ques- 
tion when  section  should  be  performed  below  and 
when  above  the  trochanter  minor. 

1.  "When  in  consequence  of  continued  disease  of 
the  hip  joint  the  head  of  the  femur  has  disappeared, 

1  "Brit.  Med.  Jour.,"  October  18,  1879,  p.  606. 


44:  OSTEOTOMY. 

leaving  only  a  stunted  nodule  of  bone,  representing 
the  neck  above  the  trochanter,  in  such  a  case  the 
operation  of  section  in  the  femoral  neck  can  not  be 
performed,  there  being  no  neck  to  divide.  This  ad- 
vanced degree  of  destruction  may  be  ascertained  by 
careful  measurement  of  the  femur  compared  with  the 
other.  Even  when  supra-trochanteric  section  is  prac- 
ticable the  state  of  the  neck  may  render  this  opera- 
tion abortive.  The  seat  of  the  operation  will  be  in 
an  almost  carious  portion  of  bone  which  is  unfit  to 
yield  a  fibrous  union,  or  possibly  atrophy  or  ne- 
crosis of  the  upper  portion  of  the  neck  may  ensue 
by  cutting  off  vascular  supply  from  bone  already 
devitalized. 

2.  "  Another  class  of  cases  inappropriate  for 
Adams's  operation  is  when,  the  anchylosis  having  re- 
sulted from  rheumatic  arthritis,  there  is  an  exuberant 
deposit  of  new  bone,  forming  hard  nodules  or  spicu- 
le around  the  femoral  neck,  itself  entire.  The  thick- 
ening and  induration  existing  will  resist  any  justifi- 
able attempts  to  divide  the  bone  in  this  situation. " 

In  cases,  however,  of  deformity  after  acute  trau- 
matic inflammation  of  the  hip,  a  high  section  is  justi- 
fiable. 

STATISTICS. 

Sections  through,  the  Neck  (68  cases). — In  17  the 
deformity  was  due  to  rheumatism;  in  27  it  followed 
hip-joint  disease ;  in  7  to  unreduced  dislocations, path- 
ological and  traumatic ;  in  1  to  osteo-myelitis  of  the 
femur  ;  and  in  16  no  cause  was  assigned.  In  3  of  the 
patients  both  hips  were  anchylosed.  The  bone  was 
divided  with  a  saw  in  40  cases,  in  15  with  an  osteo- 


DEFORMITIES  AT  THE  HIP  JOINT.  45 

tome,  and  in  12  the  instrument  is  not  mentioned.  In 
13  cases,  suppuration  followed  the  operation.  In  8 — 
Golding-Bird,1  Croft,2  Servais,3  Billroth,4  Willetts,6 
Adams,6  Holmes,7  a  case  mentioned  by  Wharton8 
and  Shaffer9 — it  was  excessive.  In  3 — Maunder10  2 
cases,  Adams  " — it  was  slight,  and  in  one  Hutchinson I2 
an  abscess  formed  at  the  seat  of  section,  but  not  con- 
nected with  the  bone  four  months  after  the  opera- 
tion. In  three  cases  there  was  more  or  less  necrosis 
following  the  operation  (Golding-Bird,  Servais,  and 
Billroth). 

Six  deaths  have  been  reported:  One  by  Croft, 
from  pyaemia,  due  to  extensive  suppuration  and  ca- 
ries of  the  head  of  the  femur.  The  deformity  was 
due  to  hip-joint  disease.  One  by  Billroth,  from  pyae- 
mia, four  months  after  the  operation,  the  deformity 
following  hip-joint  disease.  One  by  Willetts,  where 
extensive  suppuration  and  caries  of  the  head  followed 
the  section,  and  for  which  amputation  at  the  hip  joint 
was  performed,  the  patient  dying  within  twenty-four 
hours.  One  by  Adams,  eight  months  later,  from  tu- 
berculosis. One  by  Holmes,  from  exhaustion  due  to 
long  and  extensive  suppuration.  And  one  by  Shaffer, 
from  relapse  of  the  joint  disease,  followed  by  exten- 
sive suppuration  and  death,  two  years  and  a  half  after 
the  operation.  A  percentage  of  8*82  +•  It  should 
be  stated,  however,  in  justice  to  the  last  operator, 

1  "  Guy's  Hosp.  Rep.,"  N.  S.,  vol.  xxii,  p.  275. 

2  Adams,  "Trans.  Med.  Chir.  Soc,"  vol.  Ix,  p.  1. 

3  "  Rev.  de  Chir.,"  Dec,  1881,  p.  1043.     4  Langenbeck's  "  Archiv.,"  vol.  xviii. 
5  Adams's  Table,  loc.  cit.      «  Loc.  cit.       ">  "  Lancet,"  Oct.  14,  1876,  p.  535. 

8  "Am.  Jour.  Med.  Sci.,"  April,  1883,  p.  101. 

9  "  Annals  Anat.  and  Surg.,"  Dec,  1883,  p.  243. 

J0  "  Lancet,"  March  25,  1876,  p.  476.       "  Adams's  Table,  loc.  cit. 
12  "Brit.  Med  Jour.,"  March  4,  1882,  p.  298. 


46  OSTEOTOMY. 

that,  had  he  been  permitted  to  excise  the  joint  after 
suppuration  had  taken  place,  the  fatal  result  might 
not  have  followed. 

In  those  patients  in  whom  recovery  took  place 
bony  union  was  reported  in  "fifteen  cases.  Fifteen 
are  reported  to  have  some  motion  at  the  point  of 
section  at  the  time  of  dismissal.  Nineteen  were  dis- 
charged cured,  one  improved,  one  with  limb  flexed 
at  angle  of  150°,  and  in  four  the  deformity  after  a 
time  returned. 

In  regard  to  motion,  in  the  majority  of  the  cases 
it  was  only  slight.  In  two  patients  of  Lund's,  in  whom 
there  had  existed  anchylosis  of  both  hip  joints,  free 
motion  is  reported  in  one,  fourteen  and  sixteen 
months,  the  other  six  and  nine  months  after  the 
operation,  the  section  of  the  two  limbs  having  been 
performed  at  different  dates.  In  Sands's  case  fair  mo- 
tion was  obtained,  and,  I  am  informed,  lasted  for  sev- 
eral years,  but  the  false  joint  gradually  became  stiff 
and  firmly  anchylosed.  In  the  remaining  cases  the 
motion  was  in  time  lost  and  the  limbs  became  stiff. 

The  deformity  in  sixty-one  cases  consisted  of 
flexion  and  adduction,  and  in  seven  limbs  the  anchy- 
losis was  in  a  straight  position. 

Sections  below  the  Neck  (Linear),  64  cases. — The 
deformity  was  due  to  hip-joint  disease  in  39  cases ; 
to  abscess  of  the  hip  joint  after  confinement,  1 ; 
rheumatism,  2  ;  to  injury,  1 ;  in  21  cases  the  cause  was 
•not  mentioned. 

The  section  was  made  between  the  trochanters  in 
10 ;  below,  in  52 ;  in  2  cases  the  point  of  operation 
is  not  mentioned.  Only  11  operations  were  per- 
formed under  strict  antiseptic  methods  (Lister). 


DEFORMITIES  AT  TEE  HIP  JOINT.  47 

The  result  was : 

Cured  with  firm  anchylosis 52 

Cured  with  motion 2 

Result  not  satisfactory 1 

Improved 3 

Died G 

Total G4 

The  cause  of  death  was,  one  reported  by  Borchers,1 
due  to  relapse  of  the  joiut  disease  ;  one  by  Billroth,3 
from  extensive  suppuration  nine  weeks  after  the  op- 
eration ;  one  by  Billroth,3  pyaemia,  seventh  day ;  one 
by  Bryant,4  from  pyaemia,  thirty-six  days  after  an  op- 
eration for  deformity  of  both  hip  joints,  due  to  exten- 
sive suppuration  from  bed-sores ;  one  by  Porter,5  from 
exhaustion  due  to  suppuration  above  the  point  of 
operation  four  months  later,  and  one  by  Margary,6 
from  collapse  on  the  day  of  the  operation  after  a 
Volkmann  cuneiform  and  linear  osteotomy  of  the 
tibia — a  mortality  of  9'37  +  per  cent. 

Suppuration  is  reported  to  have  occurred  in  12 
cases :  Borchers,7  Stephen  Smith,6  Hamilton,9  Maun- 
der,10 two  cases ;  Rodgers,11  Maisonneuve,12  Billroth,13 
Porter,"  Margary,15  Croft,16  Moore.17 

1  "  Med.  Record,"  May  19,  1883,  p.  541. 

2  "Arch,  fur  klin.  Chirurg.,"  1882,  p.  60. 

3  "  Chirurg.  Klin.  Wien.,"  1871-'76,  p.  543. 

4  "  Lancet, "  Dec.  22,  1877,  p.  917. 

5  "Boston  Med.  and  Surg.  Jour.,"  April  18,  1878,  p.  505. 

6  "  L'Osteotomie,"  Campenon. 

I  Loc.  cit.  8  "  Med.  Record,"  June  2,  1883,  p.  589. 

9  "Ohio  Med.  Recorder,"  Aug.,  1877,  p.  97. 

10  "Trans.  Clin.  Soc,"  London,  vol.  ix,  p.  160. 

II  "New  York  Med.  and  Surg.  Jour.,"  1840,  vol.  ii,  p.  238. 

12  "Gaz.  Med.  de  Paris,"  1847,  p.  935.         13  "Ziiricher  Berichter,"  s.  552. 
14  Loc  cit.  I5  "  L'Osteotomie,"  Campenon. 

16  "Trans.  Clin.  Soc,"  London,  1877,  p.  93. 

17  "Trans.  Am.  Surg.  Association,"  vol.  i,  p.  111. 


48  OSTEOTOMY. 

In  Hamilton's,  Roclgers's,  Maisonneuve's,  and 
Moore's  cases,  the  operation  was  performed  through 
a  large  wound,  and  before  the  subcutaneous  method 
was  adopted.  In  three  patients  there  existed  anchy- 
losis of  both  hips.  (Bryant,  Ashhurst,  and  Hutchi- 
son, of  Brooklyn.) 

Cuneiform  Sections. — Of  these,  35  cases  have  been 
collected.  Of  these,  in  27  the  section  was  made  be- 
tween the  trochanters ;  in  5  the  section  was  made  be- 
low the  trochanter  minor ;  in  3  the  location  was  not 
stated — 35.  Of  these,  28  recovered  and  5  died.  In 
1  the  result  is  not  stated,  and  1  is  reported  some 
years  later  as  being  in  no  better  condition  than  be- 
fore the  operation. 

In  9  cases  suppuration  is  reported  to  have  taken 
place,  and  in  22  no  information  is  given  with  regard 
to  this  point.  In  3,  more  or  less  necrosis  is  men- 
tioned. 

The  cause  of  death  was  as  follows :  One  reported 
by  Weber,1  from  Bright's  disease;  one  by  Ders,s 
from  exhaustive  and  excessive  suppuration  ;  one  by 
Knorr,3  from  amyloid  degeneration ;  one  by  Sayre,4 
from  tuberculosis;  and  one  by  Lesrink,6  from  em- 
bolism— a  mortality  of  14"31. 

There  are  reported  3  cases  cured  with  motion; 
21  cured,  1  improved,  and  2  cured  with  anchy- 
losis in  a  straight  line.  Three  cases,  from  their 
subsequent  history,  can  not  be  put  down  as  suc- 
cessful. 

Taking  the  whole  number  of  cases  analyzed  of 

1  Rosmanit's  Statistics,  he.  cit.  2  Rosmanit's  Statistics. 

3  Langenbeck's  "Arch.,"  Bd.  v.,  s.  479. 

4  "New York.  Med.  Jour.,"  January,  1869,  p.  348. 

5  Rosmanit's  Statistics,  loc.  cit. 


DEFORMITIES  AT  THE  HIP  JOINT.  49 

osteotomy  about  the  upper  end  of  the  femur,  we 
find: 

Cured.  Died.        Failures. 

68  sections  through  the  neck 56  6  G 

64  sections  below  the  trochanters  (linear) 54  6  4 

35  sections,  cuneiform 28 


2 


138         17         12 


167 

giving  a  mortality  of  10-18. 

It  is  also  found  that,  of  the  fatal  cases,  twelve 
occurred  prior  to  1877,  and  only  five  after  that  date, 
the  cases  being  very  nearly  equal  in  number  in  these 
two  periods. 

I  think,  therefore,  that  these  tables  taken  alone 
are  misleading  in  regard  to  the  death-rate,  which  they 
make  to  appear  much  higher  than  it  really  is  under 
the  present  method  of  management  of  wounds.  It 
would  appear  that  the  fatal  cases  were  most  numer- 
ous in  the  earlier  history  of  the  operation,  before  ex- 
perience had  demonstrated  what  class  of  cases  were 
proper  ones  for  operation.  For  instance,  in  the  fatal 
case  of  Mr.  Croft,  Mr.  Adams,  although  at  the  time 
advising  the  operation,  states  later  that  his  opinion 
was  wrong.  Other  cases  of  deformity  after  hip-joint 
disease  were  subjected  to  an  operation  at  too  early 
a  date  after  the  acute  symptoms  had  subsided,  or 
the  section  was  made  too  high.  Another  cause  of 
the  increased  mortality  was  the  improper  method  of 
operation. 

Many  of  the  -earlier  sections  were  performed 
through  large  wounds,  and  extensive  dissections 
were  often  made  to  reach  the  bone.  Osteotomy, 
as  well  as  other  operations  which  have  suddenly 
become  popularized,  as  it  were,  has  suffered  from 
a    want    of    a    clear    understanding    of  the    cases 


50  OSTEOTOMY. 

suited  for  section  and  the  faulty  methods  adopted, 
and  the  earlier  operations  have  always  contrib- 
uted the  greatest  number  of  fatal  and  unrelieved 
cases. 

In  regard  to  the  question,  What  operation  should 
be  performed  %  as  mentioned  before,  cases  of  deformi- 
ties following  coxalgia  are  the  most  unfavorable  for 
section  through  the  neck,  and,  as  a  rule,  the  more 
severe  the  joint  trouble  has  been,  the  farther  from 
the  articulation  should  the  section  be  made.  The  ex- 
istence of  a  neck  is  an  absolute  necessity  in  Adams's 
operation.  The  amount  of  real  shortening  is  an  index 
of  the  extent  of  its  destruction  in  all  cases,  disloca- 
tions being  excluded.  It  should  also  not  be  for- 
gotten that  in  this  class  of  cases  an  Adams  may 
fail  to  correct,  or  the  deformity  may  return.  This 
has  happened  in  at  least  four  patients,  and  a  sec- 
tion below  the  trochanter  minor  had  to  be  per- 
formed. 

Whether  an  operation  above  or  below  the  tro- 
chanter minor  will  be  the  best,  depends  upon  the 
amount  of  shortening  of  the  muscles  inserted  at  that 
point,  and  the  extent  of  the  disease  that  has  existed 
in  the  hip  joint.  If  there  is  marked  contraction,  a 
section  above  the  trochanter  minor  will  not,  as  a 
rule,  correct  the  deformity. 

Whether  a  simple  or  cuneiform  osteotomy  should 
be  performed  is,  in  my  opinion,  of  little  moment.  The 
latter  has  been  advocated  in  deformities  accompanied 
by  marked  adduction  of  the  limb.  I  think  that  a 
linear  section  will  accomplish  as  much  as  a  cuneiform. 
There  will,  of  course,  be  a  larger  gap  to  be  filled  with 
new  bone  on  the  inner  side  than  where  a  wedge  of 


DEFORMITIES  AT  THE  HIP  JOINT.  51 

bone  has  been  removed.  Theoretically,  the  latter 
may  appear  to  be  the  better  plan,  but  practically  it 
makes  no  difference.  The  length  of  the  incision,  and 
the  fact  that  a  cuneiform  osteotomy  must  be  made 
through  a  large  wound,  does  not  add  to  the  risk, 
provided  the  wound  is  treated  properly. 

A  division  of  the  femur  performed  after  the 
method  advocated  by  Dr.  Stephen  Smith  has  no 
advantage,  I  think,  over  a  simple  osteotomy.  The 
tendency  for  the  lower  fragment  to  slip  is  not  great ; 
at  least  there  has  been  no  record,  except  in  one  case, 
of  such  an  accident,  which  the  tenon  and  mortise 
plan  did  not  prevent  in  the  case  reported. 

The  operation  has  the  theoretical  objection  of 
causing  greater  disturbance  of  the  soft  parts,  and 
makes  two  partial  sections  of  the  bone.  The  abscess 
complicating  the  case  should  be  attributed  not  to  the 
operation,  but  to  the  lack  of  drainage. 

Volkmann's  excision  of  the  hip  joint  by  means 
of  a  chisel,  as  a  substitute  for  "  osteotomacia-subtro- 
chanterica,"  has  had  but  few  advocates,  both  on  ac- 
count of  the  difficulty  and  tediousness  of  the  opera- 
tion, and  the  fact  that  but  few  cases  are  appropriate 
for  the  operation.  The  object  aimed  at  is  to  obtain 
a  movable  articulation. 

The  question  when  an  osteotomy  should  be  per- 
formed is  one  not  easy  to  answer.  The  liability  of 
strumous  joints  to  take  on  a  new  inflammatory  ac- 
tion, from  apparently  slight  injury,  even  some  time 
after  all  symptoms  of  former  trouble  have  disap- 
peared, would  indicate  that  some  months  should 
elapse  after  a  "  cure "  before  an  attempt  should  be 
made  to  correct  any  malposition.     Any  pain  about 


52  OSTEOTOMY. 

the  articulation  should  be  a  counter-indication  against 
an  operation. 

There  have  been  but  two  recorded  post-mor- 
tem examinations  after  an  osteotomy  at  the  upper 
end  of  the  femur,  one  by  Dr.  E.  M.  Moore,  of  Roch- 
ester, and  one  by  Dr.  H.  R.  Wharton,  of  Philadel- 
phia. 

Dr.  Wharton's  case  occurred  in  a  patient  nine 
years  of  age,  who  had  suffered  from  hip-joint  disease, 
and  had  recovered  with  the  limb  flexed  at  a  right 
angle,  with  rotation  outward  and  adduction.  On  No- 
vember 25,  1882,  Dr.  H.  R.  Wharton  made  a  subcu- 
taneous section  of  the  right  femur  below  the  lesser 
trochanter  with  a  saw,  which  allowed  the  limb  to  be 
brought  down  into  a  good  position ;  the  usual  dress- 
ings were  applied,  and  in  March,  1880,  the  patient 
was  walking  about  the  ward  with  the  aid  of  a  hio-h 
shoe.1  Some  months  later  a  swelling;  was  noticed  in 
the  neighborhood  of  the  great  trochanter ;  this  proved 
to  be  an  abscess  and  was  opened.  From  this  time 
the  patient  grew  rapidly  worse,  and  finally  died,  Au- 
gust 15,  1883,  from  exhaustion.  The  fatal  issue  had 
no  connection  with  the  operation,  but  was  due  to  a 
fall. 

The  specimen  consists  of  the  head,  neck,  and  a 
portion  of  the  shaft  of  the  femur  (Plates  I  and  II). 
The  head  is  denuded  of  cartilage,  but  otherwise  does 
not  show  evidence  of  much  disease.  The  section 
was  made  from  a  point  midway  between  the  tro- 
chanter major  and  minor  downward  and  inward 
(d  c,  Plate  I),  so  that  the  separation  took  place,  as 
nearly  as  can  be  judged,  in  a  line  from  this  point 

1  "  Am.  Jour.  Med.  Sci.,"  July,  1883,  p.  103. 


PLATE   I. 


Dr.  H.  E.  Wharton's  case— the  parts  after  an  intertrochanteric  operation,  anterior 

view. 


PLATE   II. 


Dr.  II.   R.  Wharton's  case— the    parts    after  an    intertrochanteric  operation,  lateral 

view. 


DEFORMITIES  AT  TEE  HIP  JOINT.  53 

through  the  middle  of  the  trochanter  minor.  There 
had  been  a  sliding  inward  of  the  lower  fragment, 
which  has  left  a  corresponding  portion  of  the  cut 
surface  on  the  upper  fragment  b  (Plate  I),  and  also 
seen  at  b  (Plate  II),  and  a  twisting  outward  on  its 
longitudinal  axis.  The  sloping  projection  (a,  Plate  I) 
is  not  due  entirely  to  the  displacement  inward  of  the 
lower  fragment,  but  in  part  to  the  rotation  men- 
tioned above.  As  the  femur  is  much  shorter  in  its 
antero-posterior  than  in  its  lateral  diameter  at  this 
point,  there  would  naturally  be  some  projection 
when  the  lower  portion  was  rotated  outward  to 
overcome  the  malposition  due  to  the  disease.  From 
an  examination  of  the  cut,  it  is  evident  that  the  de- 
formity has  been  corrected.  The  nature  and  amount 
of  the  correction  are  seen  in  Plate  II.  At  the  time 
of  the  operation  there  was  left  a  V-shaped  gap  on 
the  anterior  aspect  of  the  femur  at  the  point  of 
section ;  this  has  been  filled  up  by  new  bone  (a  a, 
Plate  II).  It  will  be  noticed  that  the  outer  line  of 
the  bone  slopes  inward,  due  to  the  sliding  in  this  di- 
rection. 

A  careful  study  of  this  specimen  shows  the  nature 
of  the  deformity  after  an  osteotomy ;  it  also  shows 
how  little  is  the  shortening  due  to  the  operation. 
The  displacement  inward  may  have  been  due  to  the 
fact  that  the  attachment  of  the  psoas  and  iliacus 
were  not  entirely  freed  because  the  section  was  not 
made  below  the  trochanter  minor,  but  through  it, 
and  these  muscles  had  drawn  the  lower  fragment  in- 
ward. 

Dr.  Moore's  patient  was  an  adult,  in  whom  there 
existed  a  dislocation  of  the  head  of  the  femur  on  to 


54  OSTEOTOMY. 

the  ilium,  just  above  the  upper  portion  of  the  lip  of 
the  acetabulum.  The  dislocation  was  primarily  back- 
ward on  to  the  dorsum  ilii,  but  by  manipulation  it 
had  been  thrown  into  the  position  mentioned  above, 
with  the  head  forward,  just  behind  the  anterior- 
superior  spine  of  the  ilium  (a,  Plate  IV),  and  all  at- 
tempts to  dislodge  it  from  this  position  failed.  The 
foot  pointed  directly  outward,  at  right  angles  to  its 
normal  position,  and  the  limb  was  hyperextended,  so 
that  walking  was  extremely  difficult.  There  was 
shortening  of  two  inches  and  a  half.  An  attempt  was 
made  to  divide  with  a  tenotome  the  bands  that  were 
supposed  to  prevent  reduction,  but  the  knife  encoun- 
tered bone  that  seemed  to  surround  the  head  and 
hold  it  in  its  abnormal  position.  An  incision  was 
then  made  down  upon  the  intertrochanteric  portion 
of  the  femur  on  its  lateral  aspect,  and  the  bone 
divided  with  a  metacarpal  saw  above  the  trochanter 
minor.  After  section,  the  limb  was  rotated  inward, 
so  as  to  bring  the  foot  into  its  normal  position, 
and  extension  by  means  of  a  weight  of  fifteen 
pounds  applied,  the  object  being  to  obtain  a  joint 
at  the  point  of  section.  Passive  motion  was  com- 
menced early,  but,  notwithstanding  persistent  efforts, 
bony  union  was  established,  the  shortening  of  the 
limb  being;  reduced  from  two  inches  and  a  half  to 
one  inch.  There  was  considerable  suppuration,  last- 
ing some  months,  but  finally  ceased  under  the  use  of 
antisyphilitic  treatment,  the  patient  exhibiting  a 
specific  eruption.  For  some  time  he  was  able  to  get 
about  comfortably  with  the  aid  of  a  cane.  He  died 
two  years  later  from  phthisis.  Plates  III  and  IV  are 
from  photographs  of  the  specimen  kindly  furnished 


PLATE  III. 


% 


Dr.  E.  M.  Moore's  ca^e— the  parts  after  an  intertrochanteric  operation,  anterior  view. 


DEFORMITIES  A  T  THE  HIP  JOINT.  55 

by  Dr.  Moore.     Plate  III  is  an  anterior  and  Plate  IV 
a  lateral  view  of  the  specimen. 

The  head  is  dislocated  and  is  seen  (a,  Plate  IV) 
just  behind  the  anterior-superior  spine  ;  the  trochan- 
ter, covered  in  this  situation  with   a  shell  of  new 
bone,  is  posterior  (&).     The  section  was  made  mid- 
way between   the   trochanters,  in    a  direction  from 
without  inward  and  a  little  downward,  to  a  point 
just  above  the  trochanter  minor.     The  head  is  per- 
fectly healthy.     It  is  held  firmly  in  its  new  position 
by  a  deposit  of  new  bone  (&,  Plates  III  and  IV),  which 
covers  it,  except  at  one  point  (#,  Plates  III  and  IV) 
and  the  upper  portion  of  the  trochanter,  and  is  con- 
tinuous anteriorly  below  with  the  mass  of  new  bone 
below  the  head,  to  be  presently  described,  while  above 
and  in  front  of  the  head  it  is  blended  with  the  ilium 
(<7,  Plates  III  and  IV).     There  is  an  enormous  mass 
of  bone,  irregular  in  shape  and  perforated  by  many 
foramina,   which  springs  from  the  anterior  portion 
of  the  shaft  from  a  point  one  inch  and  a  half  below  the 
level  of  the  trochanter  minor  (d,  Plate  IV)  and  extends 
upward  and  forward  to  a  point  on  the  ilium  just 
below  the  situation  of  the  head,  where  it  is  blended 
with  the  shell  of  bone  covering  the  head  (<?,  Plate  IV). 
This  mass  is  six  inches  and  a  half  long,  and  is  not  inti- 
mately connected  to  the  new  bone  forming  the  bond 
of  union  between  the  two  fragments.    Alarge  opening 
is  seen  at  e  (Plates  III  and  IV),  at  the  bottom  of  which 
is  seen  the  cut  surface  of  the  inferior  fragment.     The 
head  is  not  directly  united  to  the  pelvis,  but  it  is  held 
by  the  new  bone  thrown  out  around  it,  the  neck  and 
trochanter  major.     This  new  bone  is  attached  to  the 
pelves  at  g  (Plate  III).     The  new  formation  uniting 
5 


56  OSTEOTOMY. 

the  two  fragments  is  one  and  a  half  inches  long.  It 
springs  from  the  periphery  of  the  lower  fragment, 
and  from  the  shaft  immediately  below  it  (A,  Plate 
IV),  leaving  the  upper  extremity  of  the  cut  surface 
free.  A  little  above  this  point  it  is  compact,  and 
at  the  point  of  attachment  to  the  superior  portion  is 
blended  with  the  shell  of  bone  covering  the  head. 
The  new  bone  by  which  the  shaft  has  been  length- 
ened is  shown  (i  i,  Plate  IV).  The  acetabulum  is  per- 
fectly normal  (hf  Plate  III). 

This  case  is  remarkable  in  many  respects,  wheth- 
er the  dislocation,  the  enormous  growth  of  bone,  or 
the  amount  to  which  the  shortening  has  been  reduced 
is  considered.  The  practical  question  is  whether,  in 
such  cases,  a  lengthening  of  the  limb  is  possible,  and 
if  so,  what  is  the  best  method  of  accomplishing  this 

end? 

The  growth  of  bone  about  the  head  and  neck 

was  entirely  independent  of  the  operation,  and  exist- 
ed at  the  time  of  its  performance.  The  outgrowth, 
from  a  point  below  the  level  of  the  trochanter  minor 
and  extending  upward  in  front  of  the  femur,  to  be 
attached  to  the  ilium,  could  not  have  existed  at  the 
time  of  the  section,  otherwise  the  position  of  the 
limb  could  not  have  been  improved.  It  would  seem 
probable,  as  Dr.  Moore  suggests,  that  in  some  indi- 
viduals there  is  a  predisposition  for  the  growth  of 
stalactites  about  the  hip  joint,  and  that  this  abnormal 
development  of  bone  about  these  parts  in  the  patient 
from  whom  the  specimen  was  taken  may  be  attrib- 
uted to  this  predisposition.  Whether  the  presence 
of  a  specific  taint  had  anything  to  do  with  its  produc- 
tion is  an  interesting  question,  but  one  which  can  not 


PLATE    IV. 


Dr.  B.  M.  Moore's  case— the  parts  after  an  intertrochanteric  operation,  lateral  view. 


DEFORMITIES  AT  THE  IIIP  JOINT.  5? 

be  solved.  I  do,  however,  think  that,  given  the  pre- 
disposition to  exuberant  bony  formation,  the  persist- 
ent use  of  passive  motion,  in  order  to  prevent  bony 
union  between  the  fragments,  kept  up  an  irritation  of 
the  parts  which  in  this  individual  contributed  to  the 
development  of  bone  in  its  abnormal  position,  and  to 
the  extent  in  which  it  was  found.  The  limb,  after 
consolidation,  was  adducted  to  a  considerable  decree, 
and  could  not  have  been  as  useful  as  one  in  a 
straight  line  or  slightly  abducted. 

The  ultimate  results  of  all  attempts  to  obtain  a 
false  joint  at  the  point  of  section  have  not  been  very 
encouraging,  as  none  have  been  followed  by  perma- 
nent success.  In  Barton's  case,  section  between  the 
trochanters,  in  which  the  operation  was  performed 
with  this  end  in  view,  the  patient  had  useful  motion 
fur  six  years.  He  then  became  dissipated,  and  the 
joint  gradually  became  stiff,  and,  at  post-mortem  ex- 
amination two  years  later,  was  found  to  be  anchylosed. 
In  Dr.  Sands's  case '  (Adams)  the  patient  for  a  time 
(two  years)  had  a  fair  amount  of  motion.  He  then  be- 
came dissipated,  and  the  false  joint  gradually  became 
stiff.  Two  cases  are  reported  by  Lund.  There  is  no 
history  beyond  sixteen  months.  In  two  other  cases 
(Sayre's)  of  cuneiform  osteotomy  one  patient  is  re- 
ported to  have  had  a  considerable  amount  of  motion 
at  the  time  of  dismissal,  but  later  report2  is  to  the 
effect  that  suppuration  had  taken  place  and  termi- 
nated in  immobility  at  the  point  of  section.  In  the 
other  case  the  patient  died  at  the  end  of  six  months, 
and   a  false  joint  was  demonstrated.      There  were, 

1  "New  York  Med.  Jour.,"  vol.  xviii,  p.  609. 

2  "Med.  Rec,"  1878,  p.  174. 


58  OSTEOTOMY. 

however,  necrotic  changes  taking  place  in  the  bone 
about  the  new  articulation. 

It  would  seem  that  the  difficulties  attending  the 
formation  of  a  false  joint  are  great,  and,  even  if  one  is 
obtained,  it  is  a  question  whether  it  is  of  any  real  ad- 
vantage to  the  patient.  I  do  not  think  that  a  false 
point  of  motion  at  the  upper  end  of  the  femur  is  an 
advantage.  In  this  connection  Dr.  Sands  expresses 
the  following  opinion :  "  The  question  whether  opera- 
tion of  this  character  may  be  expected  to  result  in 
the  formation  of  an  artificial  joint  is  not,  in  my 
judgment,  a  very  important  one.  If  the  affected 
limb  can  be  restored  to  its  normal  position  and 
to  nearly  its  normal  length,  anchylosis  will  be 
found,  I  think,  to  afford  greater  security  than  the 
best  false  joint,  and  to  offer  no  serious  obstacle  to 
locomotion." 

It  would  appear  that,  in  those  cases  in  which  mo- 
tion at  the  point  of  section  persisted  for  some  time, 
it  was  more  of  a  hindrance  to  locomotion  than  an 
anchylosed  limb.  Further,  from  the  fact  that  the 
tendency  is  toward  a  final  anchylosis,  it  would  seem 
that  the  time  lost  in  the  attempt,  and  the  necessary 
suffering  in  trying  to  prevent  the  limb  becoming 
stiff,  were  worse  than  useless. 

The  ultimate  result  of  osteotomy  in  the  upper 
portion  of  the  femur  as  to  the  use  of  the  limb  is  ex- 
cellent. 

In  forming  an  opinion  in  regard  to  the  advisability 
in  any  case  of  performing  an  osteotomy,  the  amount 
of  adduction  should  be  considered  more  than  the  flex- 
ion. I  think  that  we  are  apt  to  look  more  at  the 
latter  wrhile  the  former  condition  is  the  main  hin- 


DEFORMITIES  A  T  THE  HIP  JOINT.  59 

drance  to  easy  locomotion.  I  think  that  a  moderately 
flexed  limb,  with  much  adduction,  is  more  of  a  real 
deformity  than  one  flexed  to  a  much  greater  degree 
without  adduction. 

Case  II  illustrates  this  point.  The  actual  short- 
ening was  one  inch,  the  real  shortening  (and  by 
that  I  mean  the  distance  of  the  foot  from  the  ground 
while  walking)  was  more  than  two  inches,  the  tilting 
of  the  pelvis  on  account  of  the  adduction  causing  the 
additional  amount  of  shortening. 

There  is  still  another  class  of  cases  of  deformity 
after  hip-joint  disease  in  which  an  osteotomy  may  be 
performed  with  advantage.  I  refer  to  cases  of  marked 
flexion  and  adduction  of  the  thigh  due  to  shortening 
of  the  psoas  and  iliacus,  and  the  adductors  in  which 
further  flexion  is  possible,  but  extension  beyond  a 
point  can  not  be  obtained.  There  is  no  doubt  but 
that  quite  a  number  of  cases  belong  to  this  category. 
Some  of  them  can  certainly  be  relieved  by  exten- 
sion upon  an  inclined  plane,  or  by  a  tenotomy  the 
adductors  can  be  freed,  but  I  am  satisfied  that  all  cases 
can  not  be  relieved  by  this  method.  I  have  failed  in 
some  cases.  Among  the  poor  it  is  impossible  to  carry 
out  with  any  degree  of  satisfaction  the  necessary 
treatment.  In  these  cases  a  section  below  the  tro- 
chanter minor  is  justifiable.  It  certainly  can  not  be 
attended  with  much  if  any  danger,  and,  although  it 
will  add  a  little  to  the  real  shortening,  it  will  in- 
crease the  apparent  length  of  the  limb  and  allow 
the  patient  to  plant  the  foot  firmly  on  the  ground 
without  any  great  amount  of  arching  forward  of  the 
lumbar  vertebras  (lordosis).  I  have  never  operated 
upon  such  a  case,  but  can  see  no  possible  objection 


60  OSTEOTOMY. 

to  it,  and  would  certainly  do  so  did  an  opportunity 
offer. 

On  the  management  of  the  limb  after  the  sec- 
tion depends  the  success  of  the  operation.  Various 
methods  have  been  adopted,  as  extension,  putting 
the  whole  limb  up  in  plaster-of-Paris,  a  long  splint, 
etc.  I  think  that  extension  and  a  long  splint  extend- 
ing from  the  axilla  to  the  foot,  with  an  angle  oppo- 
site the  point  of  section,  so  that  the  limb  may  be  held 
in  a  slightly  abducted  position,  is  by  far  the  best, 
and  plaster-of-Paris  the  worst  dressing  that  can  be 
used.  With  the  latter,  displacement  of  the  lower 
fragment  is  liable  to  occur,  and  the  pelvis  to  become 
twisted,  and  there  is  no  opportunity  to  rectify  any 
malposition.  The  case  reported  by  Dr.  E.  M.  Moore 1 
demonstrates  the  advantage  of  extension  in  these 
cases.  I  have  in  a  recent  case  adapted  this  plan  of 
treatment,  and  have  reduced  the  amount  of  shorten- 
ing to  a  considerable  degree. 

ACCIDENTS. 

Except  suppuration  and  necrosis,  but  few  acci- 
dents have  been  reported. 

Haemorrhage,  as  a  rule,  is  slight,  and  even  in 
those  sections  that  have  been  made  through  a  large 
wound  it  was  seldom  that  a  ligature  was  required. 

In  two  cases  serious  consequences  followed  from 
pressure  on  the  femoral  vessels. 

Post2  mentioned  a  case  in  which  he  had  made  a 
section  of  the  femur  just  below  the  trochanter  minor 

1  "Trans.  Am.  Surg.  Assoc,"  vol.  i,  1883,  p.  111. 

2  Report  of  "  Trans.  N.  Y.  Surg.  Soc,"  "  Annals  of  Anat.  and  Surg.,"  Janu- 
ary,  1883,  p.  30. 


DEFORMITIES  AT  THE  HIP  JOINT.  61 

through  a  large  wound.  The  limb  became  gangren- 
ous and  the  patient  died.  At  the  autopsy  it  was 
found  that  the  great  vessels  had  become  caught  over 
the  upper  fragment  of  the  bone,  and  in  that  manner 
the  circulation  in  the  limb  had  been  impeded. 

Servais x  reports  the  case  of  a  man,  twenty-three 
years  of  age,  on  whom  he  had  performed  an  Adams's 
operation.  No  accident  occurred  at  the  time,  but  on 
the  twentieth  day  profuse  haemorrhage  took  place 
from  the  femoral  artery  or  one  of  its  large  branches, 
due  to  pressure  of  one  of  the  fragments.  The  femoral 
was  ligated  and  recovery  took  place.  Maisonneuve 
is  repoi'ted  to  have  divided  the  sciatic  nerve  during 
an  operation  of  section  between  the  trochanters. 

Operations  upon  the  femur  for  the  correction  of 
deformities  after  fracture  have,  until  within  the  last 
ten  years,  been  attended  with  great  danger  and  a 
high  rate  of  mortality.  Fractures  of  the  femur  are 
more  apt  to  be  oblique  than  are  similar  injuries  of 
the  bones  of  the  leg,  and,  when  vicious  union  occurs, 
the  deformity  is  due  not  only  to  bending  at  the  seat  of 
fracture,  but  there  is  a  much  greater  amount  of  short- 
ening, due  to  overriding  of  the  fragments,  than  after 
similar  injuries  to  the  tibia.  They  are  therefore  not 
as  easily  corrected,  and  a  more  severe  operation  is  nec- 
essary. Out  of  twenty-five  cases,  in  nine  the  ends  of 
the  bones  were  resected  after  a  simple  division ;  of 
these,  suppuration  is  reported  to  have  occurred  in 
seven.  Four  patients  died — three  from  pyaemia,  one 
from  shock  after  an  amputation  of  the  limb,  and  five 
recovered.  In  seven  a  wedge-shaped  piece  of  bone 
was  removed  at  the  seat  of  fracture ;  of  these,  suppu- 

1  "Kev.  de  Chir.,"  December,  1881,  p.  1043. 


62  OSTEOTOMY. 

ration  took  place  in  three  limbs ;  two  patients  died 
— one  from  pyaemia  and  one  from  exhaustion,  and 
five  recovered.  In  nine  a  simple  section  was  made. 
Two  cases  of  suppuration  are  reported ;  two  died — 
one  from  pyaemia,  and  one  from  shock  twenty-four 
hours  after  the  operation ,  making  a  total  of  twelve 
cases  in  which  suppuration  occurred,  eight  deaths 
and  seventeen  recoveries — a  mortality  of  32  per  cent. 
In  one  case,  where  there  was  much  overriding  of  the 
fragments,  Fitzgerald 1  divided  the  callus  longitudinal- 
ly with  an  osteotome,  and  then,  by  applying  extension, 
brought  the  lower  fragment  down  and  corrected  the 
shortening.  In  some  cases  great  extending  power 
has  been  applied  by  means  of  pulleys ;  it  is  not,  how- 
ever, unattended  with  danger.  Horner,2  after  ex- 
cising the  ends  of  the  fragment,  brought  the  lower 
fragment  down  by  means  of  compound  pulleys.  He 
accomplished  his  purpose,  but  gangrene  of  the  limb 
set  in,  and  the  patient  died  on  the  fourth  day.  The 
greatest  mortality  occurred  before  the  antiseptic 
method  of  caring  for  wounds  was  known.  Since  1876 
I  can  find  no  fatal  result  reported.  Where,  from 
the  nature  or  the  position  of  the  fracture,  osteoclasis 
can  not  be  performed  and  a  section  is  necessary,  the 
choice  of  the  operation  is  not  an  arbitrary  one.  In 
many  cases  a  linear  osteotomy  will  not  yield  the  best 
results ;  the  angular  deformity  can  certainly  be  cor- 
rected, but,  when  there  is  much  overriding  and  con- 
sequent shortening  of  the  limb,  it  is  necessary  to  sepa- 
rate the  bone  in  the  line  of  the  fracture,  and  often,  in 
addition,  to  excise  the  ends  of  the  fraornents  which 


1  "  Austral.  Med.  Jour.,"  1879,  N.  S.,  vol.  i,  p.  168. 

2  "Med.  Exam.,"  Philadelphia,  1851,  N.  S.,  vol.  vii,  p.  32. 


DEFORMITIES  AT  TUE  II IP  JOINT. 


63 


may  have  become  rounded  off  and  require  to  be 
freshened  in  order  to  obtain  bony  union,  or  the 
removal  of  a  segment  of  bone  may  be  necessary  to 
bring  the  ends  of  the  bone  into  apposition.  It  is 
probable  that  cases  requiring  correction  after  frac- 
ture of  this  bone  will  be  rarely  met,  and  that,  with 
increased  facilities  and  a  better  knowledge  of  the 
management  of  these  injuries,  perfect,  or  nearly  per- 
fect, results  will  be  obtained  in  the  vast  majority  of 
cases. 

ILLUSTRATIVE    CASES. 

Case  I. — H.  B.,  ten  years  of  age,  was  admitted 
into  St.  Mary's  Hospital 
with  deformity  of  the  right 
hip  joint  following  sup- 
purative disease  of  that 
articulation.  He  has  had 
caries  of  the  spine  in  the 
middle  dorsal  region  from 
which  he  has  recovered, 
but  with  marked  deform- 
ity. Three  years  ago  the 
right  hip  joint  became  dis- 
eased, an  abscess  formed 
behind  the  great  trochan- 
ter, and  continued  to  dis- 
charge for  some  months. 
The  limb  gradually  became 
flexed  and  adducted,  so 
that  at  the  time  of  admis- 
sion it  was  in  the  condition 
shown  in  Fig.  12.     On  ex- 

&  Fig.  12. 


64  OSTEOTOMY. 

amination,  the  upper  portion  of  the  femur  is  found 
to  be  dislocated  on  to  the  dorsum  of  the  ilium ;  the 
adductors  are  strongly  contracted  and  very  tense. 
There  is  a  great  amount  of  lordosis,  but  I  think 
much  of  it  is  due  to  the  spinal  deformity.  When 
placed  on  his  back  and  the  pelvis  brought  into  its 
normal  position,  the  limb  is  flexed  at  a  right  angle 
to  the  pelvis,  and  crosses  the  left  at  a  point  above 
the  knee.  There  is  no  motion  between  the  femur 
and  pelvis.    . 

In  January,  1883,  the  following  operation  was 
performed :  An  incision  was  made  about  three  inches 
long,  extending  from  the  middle  of  the  trochanter 
major  downward,  so  that  its  center  corresponded 
with  the  trochanter  minor.  The  bone  was  found  to 
be  much  deeper  than  normal,  the  muscles  seeming  to 
be  rolled  up  over  it.  The  periosteum  wTas  raised  and 
a  V-shaped  piece  of  bone  removed  with  a  chisel  from 
a  point  just  below  the  trochanter  minor,  the  apex  of 
the  wedge  extending  into  the  compact  tissue  on  the 
inner  aspect  of  the  shaft.  The  section  was  then  com- 
pleted by  an  osteotome.  As  much  of  the  attachment 
of  the  adductors  as  could  be  safely  reached  was  then 
divided ;  also  a  portion  of  the  tensor  vaginae  femoris, 
and  the  long  head  of  the  rectus.  As  the  limb  was 
still  strongly  adducted,  other  resisting  bands  were 
torn  so  that  the  limb  could  be  brought  down  into 
a  straight  position  as  far  as  the  adduction  was  con- 
cerned. There  was  still  marked  lordosis,  which  was 
evidently  due,  to  a  considerable  extent,  to  the  spinal 
deformity.  The  edges  of  the  wound  were  partially 
united,  leaving  a  central  portion  open.  Iodoform, 
and  a  compress  secured  with  adhesive  plaster,  com- 


DEFORMITIES  AT  THE  HIP  JOINT. 


65 


pleted  the  dressing.  A  long  splint  extending  from 
the  axilla  to  the  foot,  an  extension-weight  of  five 
pounds  was  applied  after  the  patient  was  in  bed. 
The  wound  was  some  time  in  entirely  closing.  The 
patient  was  uj)  in  about  five  weeks.  Fig.  13  is  from 
a  photograph  recently 
taken.  There  appeared, 
a  few  days  after  the 
operation,  considerable 
ecchymosis,  extending 
over  the  lower  portion 
of  the  abdomen,  down 
into  the  rio-ht  scrotum 
and  the  perinasum  of  the 
same  side.  A  vessel  of 
some  size  must  have 
been  torn  in  bringing 
the  limb  into  position, 
as  the  tissues  gave  way 
with  considerable  noise. 
Case  II— B.  K., 
eleven  years  of  age,  had 
disease  of  the  left  hip 
joint  three  years  ago, 
following  a  severe  in- 
jury.  An  abscess  formed 
on  the  outer  aspect  of 
the  thigh.  At  the  time  of  admission  she  had  not 
worn  a  brace  for  eisrht  months.  The  limb  is  found 
to  be  flexed  on  the  pelvis  at  an  angle  of  140° 
and  strongly  ad  ducted.  There  is  no  motion  at  the 
hip  joint.  The  limb  is  one  inch  short.  She  walks 
with  a  very  awkward  gait,  her  toes  only  touching 


Fig.  13. 


6Q 


OSTEOTOMY. 


the  ground,  as,  on  account  of  the  adduction,  she  has 
to  raise  the  pelvis  on  the  diseased  side  so  that  it 
increases  the  apparent  shortening  to  two  inches. 
Fig.  14  shows  the  amount  of  flexion.  In  February, 
1883,  a  simple  osteotomy  was  performed  just  below 

the  trochanter  minor; 
the  adductors  and  long 
head  of  the  rectus  were 
divided,  but  the  limb 
was  not  disturbed  much, 
nor  any  persistent  at- 
tempt made  to  correct 
the  abnormal—position. 
The  lips  of  the  small 
wound  were  brought 
into  apposition  with  a 
narrow  piece  of  adhe- 
sive plaster,  and  over 
this  a  compress.  A 
long  splint  and  five 
pounds  extension  were 
applied.  On  the  third 
day  the  extension- 
weight  was  increased  to 
ten  pounds,  in  order  to 
stretch  the  muscles  and 
adhesions  so  as  to  bring  the  lower  fragment  down 
and  thus  overcome  the  adduction  and  flexion.  This 
was  accomplished  two  days  later.  On  removing  the 
weight,  it  was  found  that  the  adduction  had  entirely 
disappeared,  and  the  lordosis  was  much  diminished. 
The  weight  on  the  extension-plasters  was  reduced  to 
five  pounds.     At  the  end  of  five  weeks  the  patient 


Fig.  14. 


DEFORMITIES  AT  TEE  HIP  JO  I  XT. 


G7 


was  allowed  to  get  up.  At  the  time  of  dismissal  she 
walked  well  with  a  shoe  one  inch  hio;h,  without  the 
awkward  swinging  gait  which  she  had  at  the  time  of 
admission  (Fig.  1 5).  In  both  of  these  cases  the  tem- 
perature at  no  time  was  over  99°. 

I  have  given  these  cases  in  detail  because  I  wish 
to  emphasize  certain 
points  in  the  operation 
and  after-treatment  which 
seem  an  advantage.  I 
think  that  it  is  better 
not  to  make  any  attempt 
to  correct  the  flexion  and 
adduction  by  forcibly 
moving  the  limb  in  dif- 
ferent directions  in  order 
to  stretch  the  resisting 
bands  and  muscles.  The 
necessary  friction  be- 
tween the  fragments  is 
certainly  not  an  advan- 
tage. The  less  the  parts 
immediately  about  the 
bone  are  disturbed  the 
better,  and  the  less  lia- 
bility there  is  for  inflam- 
matory processes  to  be 
set  up.  By  extension 
with  a  weight  of  from  ten  to  fifteen  pounds,  ac- 
cording to  the  age  of  the  patient,  the  muscles  and 
bands  of  adhesion  can  be  lengthened  in  a  day  or 
two,  and,  when  this  is  accomplished  and  the  ex- 
tension let  up,  it  will  be  found  that  the  limb  can 


Fig.  15. 


68  OSTEOTOMY. 

be  placed  in  any  desired  position  without  pain. 
There  certainly  is  a  danger  that  the  soft  parts  may 
get  pinched  between  the  fragments  and  be  the  start- 
ing-point of  suppuration.  At  all  events,  it  is  a  pre- 
caution in  the  right  direction ;  it  will  certainly  ac- 
complish the  purpose  as  well  as  twisting  the  limb 
while  the  patient  is  under  ether,  and  it  would  seem 
the  better  plan.  There  is  liability  for  the  j)elvis  on 
the  same  side  as  the  limb  operated  upon  to  become 
tilted  up.  From  the  long  habit  the  patient  has  had 
of  constantly  keeping  the  pelvis  raised  in  order  to 
overcome  the  adduction,  it  will  assume  the  same 
position  during  the  rjeriod  of  consolidation,  and, 
when  the  patient  gets  up,  the  limb  is  found  more  or 
less  adducted,  much  to  the  annoyance  of  the  surgeon. 
One  may  be  easily  deceived  by  the  apparent  paral- 
lelism of  the  limb,  while  in  fact  the  limb  in  its  rela- 
.  .  / 

tion  to  the  pelvis  is  adducted.     It  is  an  advantage 

to  have  the  limb,  after  consolidation  has  taken  place, 
in  a  slightly  abducted  position,  as  it  compensates  to 
some  extent  for  the  shortening,  and  enables  the  pa- 
tient to  walk  better. 

The  statement  has  been  made  by  some  operators 
that  after  section  between  the  trochanters  the  pa- 
tient "  possessed  all  the  movements  of  the  normal 
limb."  If  by  this  it  is  intended  to  convey  the  impres- 
sion that  there  was  active  motion,  I  can  not  under- 
stand the  statement.  Quite  a  number  of  large  mus- 
cles have  their  origin  and  insertion  above  the  point 
of  section,  they  are  so  placed  for  a  purpose,  and  that 
is  to  act  on  the  femur.  Now,  if  section  is  made 
below  their  point  of  insertion,  they  certainly  can  not 
have  any  effect  on  the  motion  of  the  limb,     I  do  not 


DEFORMITIES  AT  THE  HIP  JOINT.  69 

think  that  useful  motion  is  probable  after  a  section 
between  the  trochanter  and  possibly  below  the  tro- 
chanter minor,  and  I  believe  that  a  patient  is  much 
better  off  after  an  osteotomy  for  the  correction  of  de- 
formity at  the  upper  portion  of  the  femur  with  firm 
union  between  the  fragments,  no  matter  whether  the 
section  be  at  the  neck,  between  or  below  the  tro- 
chanters. 


CHAPTER    IV. 

GENU  VALGUM;   ITS  ETIOLOGY  AND  PATHOLOGY. 

Definition. — A  deformity  at  the  knee  joint  in 
which  a  line  drawn  from  the  head  of  the  femur 
to  the  middle  of  the  ankle  joint  passes  ontside  the 
center  of  the  knee  joint,  and  in  which  the  internal 
malleoli  can  not  be  made  to  touch  when  the  limbs 
are  in  an  extended  position. 

In  discussing  the  pathology  and  etiology  of 
knock-knee,  it  will  be  necessary,  in  the  first  place,  to 
clearly  define  what  class  of  deformities  belong  to 
this  category.  Not  all  cases  of  separation  of  the 
feet  and  approximation  of  the  internal  condyles  of 
the  femur  are  to  be  classed  as  knock-knee.  In 
other  words,  not  all  cases  of  in-knee  are  cases  of 
true  genu  valgum.  If  we  examine  a  case  of  true 
knock-knee  we  find  that  the  anterior  surface  of  the 
femur  is  directed  forward;  the  feet  point  outward 
or  forward  to  a  greater  or  less  degree,  never  directly 
inward.  In  uncomplicated  cases,  when  the  legs  are 
fully  extended  on  the  thigh,  the  inner  surface  of  the 
knees  are  in  contact,  while  the  internal  malleoli  are 
more  or  less  separated,  according  to  the  degree  of 
the  deformity.  And,  on  flexing  the  leg  on  the  thigh, 
the  knock-knee  disappears.  This  is  true  genu  val- 
gum.   A  condition  that  at  first  sight  resembles  this  is 


GENU   VALGUM. 


71 


seen  in  eases  of  spastic  contraction,  in  some  cases  of 
disease  of  the  knee  joint,  and  in  a  few  examples  of 
coxals:ia  in  its  later  sta«;e.  The  whole  limb  from 
the  hip  joint  is  rotated  inward,  the  knee  is  flexed 
more  or  less  upon  the  thigh,  and  the  feet  are  turned 
inward.  In  these  cases  it  is  often  impossible  to 
fully  extend  the  leg  on  the  thigh  on  account  of  the 


Fig.  17. 


contraction  of  the  muscles  on  the  posterior  aspect 
of  the  thigh  and  leg.  They  are  no  more  cases  of 
knock-knee  than  they  are  cases  of  talipes  varus,  sim- 
ply because  the  toes  point  inward.  They  are  often 
cured  in  a  short  time  by  tenotomy  and  appropriate 
apparatus.  Patients  with  this  deformity  almost  al- 
ways walk  on  the  toes.  Any  one  can  readily 
make  his  limbs  assume  such  a  position. 

Fig.  17  is  from  a  photograph  of  a  patient  with 
6 


72  OSTEOTOMY. 

genu  valgum,  and  is  a  good  illustration  of  an  un- 
complicated case. 

If  a  perfectly  normal  adult  femur  be  disarticu- 
lated and  examined,  it  will  "be  found  that,  when  the 
bone  is  held  perpendicularly,  the  internal  condyle  oc- 
cupies a  lower  plane  than  the  external,  being  about 
one  half  of  an  inch  longer;  but  when  the  bone  is 
articulated,  the  femur  is  found  to  slant  inward  so 
that  the  condyles  are  on  the  same  level.  This  must 
needs  be,  as  the  plane  of  the  articulating  surface 
of  the  tibia  is  at  right  angles  to  the  long  axis  of 
the  body.  Owing  to  this  slanting  of  the  femur,  the 
knees  are  nearer  together  than  the  hips.  This  ob- 
liquity is  greater  in  women  than  in  men,  on  account 
of  the  greater  breadth  of  their  pelves.  There  is  also 
an  entering  angle,  the  apex  directed  inward  at  the 
knee  joint  in  the  normal  condition,  more  marked 
in  women  than  in  men.  In  a  normal  condition  of 
the  limb  the  inner  aspect  of  the  internal  condyles 
and  the  inner  malleoli  can  be  brought  together  when 
the  leg  is  fully  extended  on  the  thigh.  In  a  case 
of  cenu  valgum  the  malleoli  can  not  be  made  to 
touch,  while  the  inner  condyles  are  in  contact.  In 
some  few  cases  of  genu  valgum  there  is  some  flexion 
of  the  leg,  due  to  contraction  of  the  biceps.  This 
is  not  a  primary  condition,  but  is  secondary,  and  is 
due  to  the  fact  that  the  patient  endeavors  to  stiffen 
and  steady  the  knee  joint  by  contraction  of  this 
muscle  in  walking. 

The  knee  is  the  largest  joint  in  the  body,  and  yet 
it  is  the  weakest.  The  strength  of  the  joint  lies  not 
in  the  bones,  but  in  the  number  and  size  and  arrange- 
ment of  the  ligaments  which  unite  the  bones,  and  in 


GENU  VALGUM.  73 

the  powerful  muscles  and  fascial  expansion  that  pass 
over  the  articulation  (Morris).  It  is  a  joint  that  is 
subjected  to  a  great  amount  of  strain;  the  bones  of 
whose  extremities  it  is  formed  exert,  from  their  length, 
an  immense  leverage.  This  is  a  great  element  in  the 
production  of  deformities,  and,  at  the  same  time,  the 
chief  aid  in  their  mechanical  treatment. 

Three  theories  have  been  advanced  to  explain  the 
production  of  genu  valgum,  namely :  the  ligamentous, 
the  muscular,  and  the  osseous. 

Those  who  adopt  the  ligamentous  theory  attribute 
knock-knee  to  contraction  of  the  external  and  relaxa- 
tion of  the  internal  lateral  ligaments  of  the  knee  joint. 
But  the  anatomical  fact  that  ligaments  are  placed  to 
limit  motion,  and  have  not  the  histological  elements 
in  their  composition  to  enable  them  to  undergo  active 
contraction,  militates  against  this  theory.  The  condi- 
tion of  the  ligaments  in  genu  valgum  varies.  Some- 
times they,  are  relaxed.  In  some  cases  they  retain 
their  normal  condition.  In  others  the  external  will 
be  relaxed  while  the  internal  hold  the  inner  condyle 
and  head  of  the  tibia  in  close  apposition — just  the  re- 
verse of  what  the  advocates  of  this  theory  assume  to 
be  the  case.  In  some  cases  the  external  ligaments,  as 
well  as  the  crucial,  are  so  much  relaxed  that  the  leg 
can  be  brought  into  a  line  with  the  axis  of  the  femur 
without  the  use  of  any  force.  They  therefore  can 
not  be  an  active  agent  in  the  production  of  genu  val- 
gum. Section  of  the  ligament  has  been  found  to  be 
useless  in  the  treatment  of  this  deformity. 

Contraction  of  the  biceps  has  been  assigned  as 
the  cause  of  knock-knee.  It  is  difficult  to  under- 
stand why  this  muscle  alone  should  be  contracted, 


74  OSTEOTOMY. 

as  it  is  supplied  by  the  same  nerve  as  the  other 
muscles  at  the  back  of  the  thigh.  In  many  cases  it 
is  found  in  the  same  condition  as  the  semi-mem- 
branosus  and  semi-ten  din  osus,  neither  relaxed  or 
contracted.  Its  division  has  not  been  followed  by 
correction  of  the  deformity.  It  is  true  that  in  some 
cases  it  is  found  contracted,  together  with  the  fascia ; 
but  it  is  a  secondary,  not  a  primary,  condition. 

In  1792,  Buttcher1  drew  attention  to  the  fact  that 
in  genu  valgum  the  internal  condyle  occupied  a  lower 
plane  than  the  external  when  the  femur  was  in  its 
normal  position  ;  and  Mr.  Bishop,  in  his  work  on  de- 
formities, states  that  "the  inner  condyle  becomes  dis- 
proportionately larger  and  altered  in  figure."  Yet 
this  fact  seems  to  have  been  overlooked,  or,  from  a 
feeling  that  it  was  impossible  to  remove  it,  was 
allowed  to  be  forgotten. 

The  osseous  theory  of  genu  valgum  is  now  uni- 
versally adopted,  namely,  that  all  cases  of  knock- 
knee  are  due  to  alteration  in  the  sha]3e  of  the  bone 
about  the  knee  joint.  There  are  three  kinds  of  genu 
valgum :  A  femoral,  in  which  the  deformity  is  due 
to  changes  in  the  relation  of  the  condyles  of  this 
bone;  a  tibial,  in  which  the  malposition  of  the  leg  is 
due  to  changes  in  the  plane  of  the  tibial  heads;  or 
the  articular  ends  of  both  bones  may  be  altered  so 
that  both  contribute  to  produce  the  deformity. 

Femoral  Variety. — The  plane  of  the  femoral  con- 
dyles can  be  changed  only  in  three  ways,  namely : 

1.  By  increased  growth. 

2.  By  the  bending  of  the  lower  third  of  the  shaft. 

3.  By  atrophy  of  one  of  the  condyles. 

1  "  Brit.  Med.  Jour.,"  July  6,  1879,  p.  1. 


GENU   VALGUM. 


75 


If  the  lower  end  of  a  perfectly  normal  femur  be 
examined  on  a  living  subject,  it  will  be  found  that, 
when  the  leg  is  strongly  flexed  on  the  thigh,  the 
lowest  portion  of  both  condyles  can  be  readily  made 
out,  and,  if  the  thigh  be  held  in  its  natural  position,  it 
is  very  easy  to  judge  of  the  relative  lengths  of  the  two 
condyles.  While  the  limb  is  held  in  this  position  a 
narrow  piece  of  sheet  lead  can  be  molded  across  the 
joint,  and  from  this  a  correct  outline  of  the  articular 
end  of  the  bone  can  be  obtained  and  traced  on  paper. 
That  the  internal  is  in  some  cases  increased  in  length, 

O  1 


'/i- 


Fig.  18. 


Fig.  19. 


and  thus  occupying  a  lower  plane  than  the  external, 
has  been  demonstrated  by  post-mortem  examinations 
and  recorded  by  Delore,  De  Santi,  Lannelongue,  and 
others. 

Figs.  18  and  19  are  from  a  tracing  of  a  case  of 
unilateral  genu  valgum,  showing  the  difference  in  the 
position  of  the  internal  condyles  in  the  two  limbs. 
The  *  indicating  the  position  of  the  internal  condyle. 

Dr.  Clark  demonstrated  the  same  fact  in  a  careful 
measurement  of  one   hundred   and   sixty-six   limbs 


76  OSTEOTOMY. 

(belonging  to  one  hundred  patients)  affected  with 
knock-knee,  and,  comparing  them  with  one  hundred 
measurements  of  normal  limbs,  in  seventy  per  cent 
there  was  an  abnormal  increase  of  the  internal  over 
the  external  condyle.  Allowing  that  in  the  normal 
limb  the  internal  condyle  averages  about  one  quarter 
of.  an  inch  over  the  external  condyle,  all  above  this 
was  considered  abnormal.  In  persons  under  ten  years 
of  ao-e  there  would  be  less  difference  between  the 
length  of  the  two  condyles  than  one  quarter  of  an 
inch.  This  would  raise  the  percentage  to  over  eighty- 
four.  Of  the  one  hundred  and  seventeen  cases  in 
which  the  internal  condyle  was  over  the  normal 
length,  the  extent  of  the  abnormality  in  fourteen  cases 
was  under  a  quarter  of  an  inch.  In  fifty-four  it  was 
a  quarter  of  an  inch.  In  thirty-five  it  was  over  a 
quarter  of  an  inch  and  not  more  than  half  an  inch. 
In  nine  it  was  between  a  half  and  under  an  inch.  In 
four  it  measured  an  inch,  and  in  one  it  was  an  inch 
and  a  quarter.1 

De  Santi  states  that  the  hypertrophy  is  confined 
to  the  vertical  diameter  of  the  condyle.  Gueniot 
found  the  same  condition,  but  with  an  evident  dimi-. 
nution  in  the  antero-posterior  diameter. 

I  have  also  noticed,  together  with  an  evident  in- 
crease in  the  length  of  the  condyle,  a  spur-like  growth 
from  its  inner  surface,  extending  beyond  the  line  of 
the  tibia. 

A  curvature  of  the  lower  third  of  the  femur  with 
the  convexity  inward  will  cause  a  depression  of  the 
internal  and  an  elevation  of  the  external  condyle.  Or 
it  may  be  looked  upon  as  a  tilting  of  the  lower  end  of 

1  Macewen,  "  Osteotomy,"  p.  44. 


GENU  VALGUM.  77 

the  bone  in  a  direction  from  within  outward  and  up- 
ward. In  the  majority  of  cases  in  which  the  deformity 
appears  early  in  life  I  have  generally  found  it  due  to 
the  bending  of  the  bone ;  in  addition  to  this  there 
may  be  a  change  in  the  epiphysis.  It  is  not  placed 
squarely  on  the  diaphysis,  but  is  twisted  more  or 
less,  the  cartilage  is  thickened,  may  be,  over  the 
internal  condyle,  while  that  over  the  external  portion 
of  the  bone  may  be  flattened  and  crowded  out  over 
the  epiphysis.  The  latter  is  due  to  the  weight  of 
the  body  acting  upon  the  softened  bone. 

There  is  yet  another  change  met  with  at  post 
mortem,  and  which  is  a  cause  of  this  deformity, 
namely,  a  flattening  of  the  external  condyle;  or  it 
may  undergo  a  true  atrophy.1 

From  a  plate  in  Delore,  it  is  evident  that  the 
femur  may  be  bent  near  its  neck  so  as  to  throw  the 
trochanteric  and  subtrochanteric  portion  of  the  shaft 
outward. 

The  femur  often  has  an  anterior  bend. 

In  not  a  few  cases  of  knock-knee  a  careful  exami- 
nation reveals  nothing  abnormal  in  the  shaft  of  the 
femur  or  its  condyles,  the  latter  being  in  the  same 
plane ;  but  the  articulating  surfaces  of  the  tibia  are  not 
on  the  same  level,  the  inner  head  of  the  tibia  being 
on  a  much  higher  level  than  its  external,  thus  throw- 
ing the  axis  of  the  tibia  outward,  or  the  diaphysis  of 
the  bone  may  be  united  to  the  epiphysis  at  an  angle. 

Often  the  deformity  in  genu  valgum  is  due  to 
changes  taking  place  in  both  the  femur  and  tibia. 

I  have  never  met  with  a  case  of  true  genu  valgum 
that  was  not  due  to  osseous  changes. 

1  Hows?,  "  Guy's  Hosp.  Report,"  vol.  xx,  p.  531. 


78  OSTEOTOMY. 

These  changes  in  the  shape  of  the  bones  are,  in  a 
certain  class  of  cases,  often  accompanied  by  other 
curves  of  the  long  bones  of  the  lower  extremities. 
It  is  evident  that  in  many  cases  of  the  deformity  one 
factor  can  not  be  assigned  as  the  sole  cause  of  the 
the  malposition  of  the  tibia. 

The  condition  of  the  ligaments  about  the  knee 
joint  in  genu  valgum  varies.  Often  there  is  no 
change  except  such  as  is  secondary  to  the  deformity 
— namely,  a  lengthened  internal  lateral  ligament,  cor- 
responding to  the  increased  size  of  the  condyle ;  but 
there  is  no  relaxation.  Sometimes  the  external  li^a- 
ment  is  very  much  relaxed,  so  that  the  tibia  can  be 
brought  into  a  straight  line  with  the  long  axis  of 
the  femur  without  the  use  of  any  more  force  than  is 
necessary  to  move  the  limb,  an  interval  being  found 
between  the  external  condyle  and  the  corresponding 
point  of  the  tibia.  Both  ligaments,  together  with  the 
crucial,  may  be  so  much  lengthened  that  the  leg  can 
be  moved  very  freely  in  both  lateral  directions.  Too 
much  force  applied  during  mechanical  treatment  has 
been  the  cause  of  this  lengthening  of  the  external 
ligament  in  some  cases. 

It  is  evident  from  this  that  the  condition  of  these 
structures  varies,  and  that  they  can  have  no  direct 
cause  in  the  production  of  the  deformity. 

Such  being  the  changes  found  in  the  bones  in 
genu  valgum,  the  next  inquiry  is  as  to  their  cause. 

There  are  two  periods  during  which  knock-knee 
is  first  developed :  namely,  in  children  between  the 
first  and  fifth  }Tears  of  age,  and  in  young  persons 
between  the  twelfth  and  twentieth  years,  the  first 
corresponding  to  the  term  during  which  diseases  of 


GENU  VALGUM.  79 

malnutrition  are  so  common,  the  second  to  the  pe- 
riod of  rapid  growth.  Between  these  two  dates — 
namely,  from  the  sixth  to  the  twelfth  year — genu 
valgum  is  rarely  developed.  The  etiology  of  the  de- 
formity in  these  two  periods  differs. 

In  genu  valgum  coming  on  before  the  fifth  or 
sixth  year,  rickets  is  the  predisposing  cause.  I  have 
never  seen  a  case  of  the  deformity  in  a  child  under 
six  years  of  age  in  which  there  was  not  unmistak- 
able signs  of  this  disease.  In  a  perfectly  healthy 
child — one  who  has  been  properly  nourished  and 
has  breathed  pure  air — knock-knee  will  not  be  de- 
veloped ;  at  least  I  have  never  met  with  such  a  case, 
nor  do  I  know  of  any  recorded  example  of  this  de- 
formity appearing.  Normal  bones  do  not  become 
distorted. 

The  case  is,  however,  different  in  children  who 
have  been  improperly  nourished  and  who  have  lived 
in  bad  hygienic  surroundings.  Those  who  have  been 
brought  up  under  such  circumstances  develop  these 
deformities.  At  this  age,  and  at  the  time  of  the  great- 
est intensity  of  the  rachitic  changes  in  the  bone  (soft- 
ening), any  alterations  in  the  shape  of  the  shaft  of 
the  femur  or  in  the  articulating  ends  of  the  bone 
and  the  tibia  may  occur.  Tripier  advances  the  theory 
that  the  epiphyseal  cartilage  first  becomes  thickened 
and  the  limb  lengthened,  and  later  the  weight  of 
the  body  determines  the  bend,  according  as  the  in- 
tensity of  the  softening  has  fallen  upon  the  epiphy- 
seal cartilage  or  the  shaft  of  the  bone.  The  im- 
mediate cause  is  mechanical.  In  children  who  are 
too  young  to  walk,  the  manner  in  which  they  are 
carried  about  has  been  assigned.     In  fact,  any  posi- 


80  OSTEOTOMY. 

tion  that  can  act  on  the  soft  bones  may  cause  them  to 
bend.  Cases  have  been  recorded  of  congenital 
genu  valgum. 

The  cause  of  genu  valgum  coming  on  after  the 
twelfth  year  has  given  rise  to  much  discussion,  and 
has  received  many  explanations.  Macewen,  in  his 
admirable  work  on  osteotomy,  considers  that  the  de- 
formity, as  in  the  infantile  variety,  is  due  to  rickets, 
and  gives  the  histories  of  three  cases  in  proof  of 
his  statement.  In  one,  profuse  perspiration  about 
the  head,  curvature  of  the  long  bones  of  the  lower 
extremities,  swelling  of  the  epiphyses  of  the  fore- 
arm, and  marked  bow-legs,  came  on  in  a  lad  of  fifteen 
years  of  age,  who,  previous  to  this  attack,  had  been 
perfectly  healthy.  The  other  two  cases  are  not 
given  with  sufficient  detail.  The  author  simply 
states  that  they  developed  knock-knee,  preceded  by 
a  train  of  symptoms  only  referable  to  rickets.  The 
history  of  the  first  case  certainly  corresponds  to  that 
of  rickets.  But  whether  all  cases  of  genu  valgum 
coming  on  after  the  twelfth  year  should  be  considered 
as  due  to  this  disease,  I  doubt.  It  is  true  that 
other  writers  have  maintained  the  advent  of  rickets 
during  adolescence,  but  these  statements  have  been 
questioned  by  many  able  observers. 

My  own  experience  is  limited  to  four  cases,  but, 
as  they  seemed  to  throw  some  light  on  this  subject, 
it  may  be  of  interest  to  record  them.  For  the  use 
of  these  cases  I  am  indebted  to  my  friend,  Dr. 
Gibney. 

Case  I. — F.,  fourteen  years  of  age,  has  always  been 
delicate  ;  is  now  in  fair  condition  ;  for  the  past  year 
has  been  growing  rapidly.     No  symptoms  of  rickets, 


GENU   VALGUM.  81 

past  or  present,  can  be  detected.  Within  the  last 
eight  months  a  double  genu  valgum  has  been  de- 
veloped. Both  internal  condyles  are  on  a  lower 
plane  than  the  external.  There  is  no  abnormal 
bend  of  either  femur  or  tibia,  no  tenderness  over 
the  line  of  the  epiphyseal  cartilage,  and  no  enlarge- 
ment of  the  ends  of  any  of  the  long  bones. 

Case  II. — M.,  seventeen  years  of  age,  has  always 
been  healthy.  For  the  past  year  has  been  employed  as 
a  wagon  driver  for  agroceiyman.  Has  had  to  jump  out 
of  his  wagon  very  often,  and  always  coming  down  on 
his  left  foot.  For  the  past  year  has  been  growing  very 
rapidly.  Two  months  ago  he  noticed  that  in  walk- 
ing his  left  knee  bent  inward.  The  patient  is  mus- 
cular and  well  developed.  He  has  never  had  any 
perspiration  about  his  head,  nor  any  other  rachitic 
symptoms. 

On  examination,  he  is  found  to  have  knock-knee 
in  the  left  limb.  There  was  no  abnormal  bending 
in  either  the  femur  or  tibia,  no  enlargement  of  the 
ends  of  the  long  bones.  The  condyles  of  the  left 
femur  are  on  the  same  plane,  but  the  inner  head  of 
the  tibia  is  much  higher  than  the  outer,  and  is  evi- 
dently the  cause  of  the  abnormal  position  of  the  leg. 
The  ligaments  are  normal. 

Case  III. — M.,  sixteen  years  of  age,  is  well  devel- 
oped and  muscular.  He  has  always  been  healthy. 
For  the  past  two  years  has  been  employed  in  a  factory 
where  he  has  to  stand  all  day  and  swing  a  heavy  mal- 
let. He  is  certain  that  his  limbs  were  perfectly  straight 
until  three  months  ago,  when  they  began  to  bend  in- 
ward at  the  knee.  This  bending  inward  has  been 
increasing.     He  has  been  free  from  pain  until  within 


82  OSTEOTOMY. 

the  last  week.  Since  then  has  suffered  considerably 
after  standing  or  walking.  The  left  limb  is  more 
deformed  than  the  right. 

Left  Knee. — There  are  two  spines — one  two,  the 
other  three  inches  below  the  inner  head  of  the  tibia 
on  the  lateral  aspect.  They  are  quite  tender  upon 
pressure.  The  line  of  the  epiphyseal  cartilage  of 
both  the  femur  and  tibia  are  tender  on  pressure. 
There  is  some  lateral  motion  at  the  knee  joint. 
There  is  effusion  into  the  left  knee  joint,  and  it 
measures  one  inch  more  in  circumference  than  the 
right. 

Right  Knee. — There  are  two  spines  in  the  same 
position  as  those  in  the  left,  but  smaller  and  not  so 
tender.  The  joint  is  not  swollen ;  the  epiphyseal 
line  of  both  bones  is  tender.  The  condyles  of  both 
femora  are  on  the  same  planes,  while  the  inner  heads 
of  both  tibiae  are  higher  than  the  external.  There 
are  no  symptoms  of  rickets,  either  in  bending  of  long 
bones  or  enlargement  at  their  extremities.  Patient 
states  that  he  has  increased  six  inches  in  height  dur- 
ing the  past  year.     He  weighs  164  pounds. 

Case  IV. — M.,  nineteen  years  of  age,  baker,  states 
that  he  has  always  been  healthy.  Is  rather  young- 
looking  for  his  age.  He  first  noticed  that  he  was  be- 
coming knock-kneed  nine  months  ago.  Both  limbs  are 
cedematous,  and  feel  flabby.  The  condyles  of  both 
femora  are  perfectly  normal  in  position.  The  shafts  of 
both  tibiae  seem  united  to  the  epiphysis  at  an  angle. 
The  articular  ends  of  these  bones  are  on  a  level. 
There  is  no  tenderness  anywhere  about  the  joints. 
There  is  slight  lateral  motion  at  both  knees.  The 
tarsal  arch  is  flattened.     The  deformity  is  evidently 


GENU  VALGUM.  83 

tibial.  The  patient  has  been  growing  rapidly  during 
the  past  year.  His  work  compels  him  to  stand  most 
of  the  night  with  his  leg  adducted  and  knees  slightly 
flexed. 

These  four  cases  have  one  thing  in  common :  that 
the  deformity  developed  during  rapid  growth.  In 
three  it  occurred  in  persons  who  gave  no  history  of 
any  illness,  and,  with  the  exception  of  the  deform- 
ity, two  of  them  would  have  been  considered  as  types 
of  healthy  development.  There  were  certainly  no 
signs  of  rickets.  In  two  cases  the  deformity  was  due 
to  position — standing  during  long  working-hours — 
in  the  other,  jumping  frequently  from  a  wagon,  and 
always  alighting  on  the  same  limb. 

It  is  a  well-known  fact  that  the  increase  in  the 
length  of  the  lower  limbs  takes  place  to  a  great  de- 
gree by  deposit  of  new  material  between  the  diaphy- 
ses  and  epiphyses  of  the  femur  and  tibia.  If  the 
formation  of  new  bone  elements  (cartilage-cells)  is 
more  rapid  than  the  ability  of  the  system  to  supply 
the  earthy  salts  for  their  calcification,  this  new  mate- 
rial would  be  liable  to  yield  in  any  direction  under 
persistent  force.  This,  I  believe,  is  the  explanation 
of  the  advent  of  the  deformity  in  the  cases  men- 
tioned above.  That  this  increased  activity  of  forma- 
tive process  was  great  is  evidenced  in  growth  of 
spine  over  the  tibia,  and  the  effusion  into  the  knee 
joint.  Tenderness  on  pressure  over  the  epiphyseal 
cartilage  adds  weight  to  the  view. 

In  regard  to  tibial  spines,  Macewen  states  that 
they  are  a  prominent  feature  in  many  cases  of  knock- 
knee  ;  that  they  are  more  frequently  found  in  infan- 
tile cases  than  in  s;enu  valgum  adolescentium.     He 


84  OSTEOTOMY. 

gives  the  percentage  as  high  as  sixty-nine.  I  have 
never  met  with  them  except  in  the  case  given  above, 
although  they  have  been  looked  for.  They  must  be 
of  much  less  frequent  occurrence  here  than  among 
the  children  coming  under  that  gentleman's  observa- 
tion. 

The  cause  of  abnormal  increase  in  the  internal 
condyle  has  never  been  satisfactorily  explained. 
Whether  the  theory  of  increased  nutritive  activity 
in  the  epiphyseal  cartilage  over  the  condyle  is  the 
correct  one  has  never  been  proved. 

Genu  valgum  is  seen  after  convalescence  from 
disease,  as  typhoid  and  scarlet  fever.  The  deformity 
has  been  known  to  develop  during  rheumatic  fever, 
but  the  pathological  process  has  never  been  recorded. 
Gould1  exhibited,  at  the  London  Pathological  Society, 
a  specimen  removed  by  amputation,  in  which,  together 
with  obliquity  of  both  epiphyses,  there  were  marked 
symptoms  of  rheumatic  arthritis.  Haward2  mentions 
a  case  in  which  marked  hypertrophy  of  the  external 
condyle  was  found  in  a  knee  joint  affected  with  rheu- 
matism. Richardson3  demonstrated  the  intrinsic  en- 
largement of  the  condyle  from  disease.  I  have  never 
seen  a  case  of  true  knock-knee  in  disease  of  the  knee 
joint,  although  a  great  many  joints  have  been  ex- 
amined for  this  purpose.  There  is  often  an  appear- 
ance resembling  this  deformity,  but  I  have  never  been 
able  to  satisfy  myself  that  true  knock-knee  existed. 

Morris*  mentions  the  case  of  a  boy  who,  some 
years  before,  injured  the  upper  portion  of  his  tibia. 

111  Brit.  Med.  Jour.,"  January  21,  1S82,  p.  87. 
2"  St.  George's  Hosp.  Report,"  1879,  p.  46G. 
8 "Med.  Press  and  Circ.,"  1879,  xxvii,  p.  322. 
4 "Brit.  Med.  Jour.,"  May  21, 1881,  p.  809. 


GENU  VALGUM.  85 

This  was  followed  by  necrosis.  At  the  time  of  ob- 
servation the  inner  head  of  this  bone  was  found 
greatly  enlarged,  so  that  it  occupied  a  higher  plane 
than  the  external,  producing  well-marked  genu  val- 
gum of  the  limb. 

Beauer1  records  a  case  of  genu  valgum,  due  to 
diastasis  of  the  lower  epiphysis  of  the  left  femur  sub- 
sequent to  an  injury,  in  which  the  lower  portion  of 
the  bone  had  become  dislocated  outward,  and  for  the 
correction  of  which  excision  of  the  knee  joint  was 
performed. 

A  case  of  deformity,  having  all  the  characteristics 
of  genu  valgum,  due  to  a  fracture  at  the  lower  end  of 
the  femur,  is  reported  by  Molliere.'  It  was  corrected 
by  refracture  by  Robin's  osteoclast. 

It  is  evident  then  that  o;enu  valgum  can  not  be 
explained  on  any  one  theory,  but  that  many  causes 
combine  to  produce  it,  and  that  the  deformity  is  due 
to  changes  in  the  bones  forming  the  knee  joint. 

That  true  genu  valgum  is  capable  of  a  spontaneous 
cure — that  is,  without  any  treatment — is  doubtful. 
From  the  nature  of  the  deformity  it  is  difficult  to 
understand  what  reparative  or  corrective  force  could 
act  so  as  to  obliterate  the  abnormal  curvature  of  the 
bone  or  change  the  relation  of  the  condyles  when  the 
deformity  is  due  entirely  to  differences  in  their  plane. 
Macewen,3  in  speaking  of  spontaneous  cures,  says 
that  "  there  can  be  no  doubt  that  cases  have  occurred 
during  childhood  when  the  deformity,  though  at  one 
time   marked,  has   undergone   rectification    without 

1  "Orthopaedic  Surgery,"  1868,  p.  192. 

2"  Lyon  med.,"  December  23,  1883,  p.  549. 

3  "  Osteotomy,"  p.  92. 


86  OSTEOTOMY. 

operative  interference,"  yet  in  the  following  line  men- 
tions the  necessity  for  some  kind  of  treatment. 

It  is  true  that  limbs  atfected  with  this  deformity 
have  been  reported  as  having  become  straight  in 
later  years  without  any  treatment  whatever,  and  that 
children  have  "outgrown"  it.  But  the  details  of 
such  cases  have  been  so  meager  as  to  raise  a  reasona- 
ble doubt  as  to  the  nature  of  the  deformity.  No  case 
has  fallen  under  my  own  observation,  nor  have  I  been 
able  to  satisfy  myself  that  they  have  occurred. 

Symptoms. — A  person  with  genu  valgum  to  any 
marked  degree  walks  with  difficulty,  is  easily  fa- 
tigued, and  locomotion  is  often  painful  and  almost 
impossible.  In  infancy  and  early  childhood  these 
patients  are  often  able  to  get  about,  but  with  fre- 
quent falls.  Later  they  seem  to  acquire  the  habit 
of  balancing  themselves  better,  and  walk  and  even 
run,  but  awkwardly.  In  later  years  locomotion  often 
becomes  again  difficult  and  painful,  so  that  crutches 
have  to  be  used. 

The  more  relaxed  the  ligaments  the  greater  is  the 
difficulty  in  getting  about.  The  deformity  may  be 
so  great  that  the  knees  are  crossed  in  standing.  Genu 
valgum  may  affect  both  limbs  or  only  one.  If  the 
former  case,  it  is  generally  more  marked  on  one  side 
than  on  the  other. 

In  marked  cases  the  patella  is  dislocated  out- 
ward, and  is  found  riding  over  the  external  condyle, 
being  forced  into  this  position  by  the  change  in  the 
axis  of  the  tibia,  or  it  may  slip  during  flexion  to  the 
outside  of  the  condyle.  I  have  met  with  several 
cases  of  the  deformity  in  adults  complicated  with 
effusion  into  the  joint,  accompanied  with  considerable 


GENU   VALGUM.  87 

pain.  Loose  bodies  are  found  in  rare  cases  in  the  cav- 
ity of  the  joints  in  those  well  advanced  in  years,  but 
these  may  have  had  no  connection  with  the  deformity. 
The  shape  of  the  foot  varies  in  knock-knee.  Mac- 
ewen x  states  that  the  foot  is  well  arched,  the  instep 
high,  and  the  patient  walking  principally  on  its  out- 
side. When  the  foot  is  nude  and  the  joatient  walks, 
the  extensor  and  the  flexor  muscles  are  seen  to  be 
brought  well  into  action,  and  the  toes  seem  to  grasp 
the  floor  in  endeavoring  to  maintain  the  equilibrium. 
I  do  no  think  that  this  statement  is  strictly  correct.  I 
have  seen  advanced  cases  in  which  the  arch  of  the  foot 
was  flattened,  although  the  child  was  walking  about. 
And  in  one  of  the  patients  with  genu  valgum  adoles- 
centium  there  was  marked  dropping  of  the  arch. 
In  many,  however,  the  condition  mentioned  by  Mac- 
ewen  is  found  to  exist.  Knock-knee  is  often,  in  ra- 
chitic subjects,  complicated  with  other  curves  of  the 
long  bones,  as  in  Fig.  20,  taken  from  a  photograph 
of  a  patient  at  present  under  treatment. 

Mikulicz2  has  recorded  the  result  of  some  post- 
mortem examinations  of  limbs  affected  with  genu 
valgum.  He  found  that  there  had  been  an  increase 
of  that  portion  of  the  diaphysis  of  the  femur  over  the 
internal  condyle,  placing  it  on  a  lower  plane  than  the 
external. 

Contraction  of  the  biceps  is  seen  in  some  c^ses  of 
long  standing.  It  is  not  a  primary  condition.  It  is 
due  to  the  patient  attempting  to  stiffen  the  knee 
joint  in  walking  and  standing.  In  advanced  cases 
there  may  be  some  flexion  of  the  leg  on  the  thigh, 

1  Loc.  tit,  p.  34. 

2  "  Archiv.  klin.  Chirurg.,"  vol.  xxiv,  1879,  p.  192. 

7 


88 


OSTEOTOMY. 


and  secondary  contraction  of  the  fascia  on  the  outer 
aspect  of  the  limb.  These  may  also  exert  some  rota- 
tion of  the  tibia  outward. 

The  treatment  of  knock-knee  is  mechanical  and 
operative. 

1.  Mechanical  Treatment. — That  genu  valgum  can 
be  cured  by  the  use  of  splints  in  both  infantile  and 
adolescent  cases  is  a  question  concerning  which  there 


Fig.  20. 


is  no  doubt,  if  they  are  placed  under  proper  treatment 
during  the  early  stage  of  the  disease — that  is,  before 
the  bones  have  become  hardened  and  the  epiphyses 
fixed  to  the  diaphyses.  The  period  during  which  we 
may  reasonably  expect  to  correct  the  deformity  de- 
pends upon  the  general  health  of  the  patient  and  the 
rapidity  with  which  the  earth-salts  are  deposited  in 
the  bone-cells.     It  should  be  remembered  that  the 


GENU   VALGUM.  89 

degree  of  softening;  sometimes  varies  in  different  bones 
of  the  same  individual,  so  that  one  limb  may  be 
straightened  by  braces  while  in  the  other  they  are 
useless.  Braces  for  the  correction  of  this  deformity 
should  extend  from  the  trochanter  to  the  external 
malleolus.  They  should  permit  of  no  flexion  of  the 
leg  on  the  thigh,  and  they  should  be  of  sufficient 
strength  to  exert  a  continuous  force  on  the  bones  of 
the  limb  in  a  direction  from  within  outward.  The 
power  may  be  applied  either  with  a  bandage  or 
leather  straps.  A  simple  well  padded  wooden  splint 
may  be  used,  to  which  the  whole  limb  is  firmly 
bandaged,  or  a  steel  instrument  may  be  applied. 
The  patient  should  not  be  allowed  to  walk  more 
than  is  necessary.        . 

The  object  aimed  at  in  the  treatment  of  genu 
valgum  by  orthopaedic  appliances  is  to  so  act  on  the 
femur  that  the  leg  will  be  thrown  directly  inward. 
If  the  femur  is  still  pliable,  and  the  external  lateral 
ligament  strong,  this  bone  will  be  thrown  outward  at 
the  lower  third  and  the  depressed  condyle  raised.  If, 
however,  the  external  lateral  ligament  is  relaxed  or 
weakened,  the  tibia  will  be  drawn  into  a  straight 
line  with  the  long  axis  of  the  femur,  but  no  change 
will  take  place  in  the  femoral  curve.  The  external 
ligament  will  allow  the  tibia  to  be  swung  inward  on 
the  internal  condyle  as  a  center,  leaving  a  space  be- 
tween the  external  condyle  and  the  outer  head  of  the 
tibia,  and  thus  no  direct  force  can  be  applied  to  the 
femoral  curve. 

I  am  satisfied  that  this  is  one  cause  of  the  want 
of  success  in  the  mechanical  treatment  of  infantile 
knock-knee.     In  such  a  case,  if  the  tibia  be  held  in 


90  OSTEOTOMY. 

its  normal  position,  and  the  patient  allowed  to  go 
about,  the  weight  of  the  body  will  fall  upon  the  in- 
ternal condyle,  and,  provided  the  bone  is  still  soft,  it 
may  yield  and  the  deformity  be  permanently  cor- 
rected. It  is  evident  that  in  cases  where  the  external, 
lateral,  and,  of  course,  the  crucial,  ligaments  are  weak, 
care  should  be  taken  that  but  slight  traction  be  made 
upon  these  tissues  by  much  force  being  applied  to 
the  tibia.  A  relaxed  lateral  ligament  is  as  much  of  a 
hindrance  to  walking  as  a  valgoid  knee  with  unre- 
laxed  ligaments.  Dr.  N.  M.  Shaffer  thinks  that,  in 
cases  due  to  increased  growth  of  the  internal  condyle, 
by  relieving  the  external  condyle  from  pressure  it 
takes  on  a  more  rapid  growth,  and  thus  fills  up  the 
interval  between  the  external  portion  of  the  femur 
and  tibia.  At  an  early  stage  of  rickets,  thus  trans- 
ferring the  weight  from  the  external  to  the  internal 
condyle  may  cause  the  latter  to  become  flattened,  or 
even  atrophied. 

In  adolescent  cases  the  time  of  increase  of  the 
deformity  is  the  only  period  during  which  we  may 
hope  for  any  change  in  the  limb  by  mechanical  means, 
and  it  should  be  the  time  of  active  treatment,  as  the 
new  soft  bony  tissue  soon  becomes  dense  and  hard, 
the  epiphysis  becomes  united  to  the  diaphysis,  and 
correction  is  not  possible. 

In  proof  of  the  statement  that  the  mechanical 
treatment  of  genu  valgum  is  far  from  satisfactory,  we 
would  refer  to  the  statistics  of  a  well-known  ortho- 
paedic dispensary  in  this  city,  at  which  patients  re- 
ceive the  best  of  care  and  attention,  and  where  they 
are  placed,  as  far  as  the  mechanical  management  of 
the  case  is  concerned,  under  the  most  approved  meth- 


GENU  VALGUM.  91 

ods.  From  1876  to  1883  there  were  treated  99  cases 
of  knock-knee.  Of  this  number  only  13  were  over 
five  years;  17  were  discharged  cured;  48  relieved; 
8  discharged  for  neglect;  and  29  were  still  under 
treatment,  making  about  23  per  cent  of  cures.  In 
arriving  at  these  figures,  we  have  looked  upon  the  48 
discharged  relieved  as  though  they  had  been  dis- 
missed unrelieved.  Or,  looking  at  these  cases  in  the 
most  favorable  light  —  that  is,  deducting  the  13 
patients  over  five  years  of  age  as  being  incurable — 
we  find  that  out  of  60  cases  17  were  cured;  not 
quite  30  per  cent. 

The  simpler  the  mechanical  support  the  better. 
I  have  seen  a  perfect  result  from  the  use  of  a  simple 
straight  wooden  splint  in  a  girl  three  years  of  age,  in 
whom  the  bones  were  very  pliable. 

No  rule  can  be  laid  down  as  to  the  age  beyond 
which  mechanical  treatment  will  fail  from  the  harden- 
ing of  the  bones.  I  think,  however,  that  the  amount 
of  spring  there  is  in  the  tibia  is  something  of  a  guide. 
If  one  grasps  the  leg  just  above  the  ankle  with  one 
hand,  and  below  the  knee  with  the  other  hand,  and 
attempts  to  bend  the  bone  in  a  healthy  child  of  two 
or  three  years  of  age,  it  will  be  found  that  it  will 
not  yield  with  the  use  of  any  force  that  can*  be  borne. 
In  a  rickety  child,  with  soft  bones,  the  tibia  will  be 
felt  to  yield,  even  up  to  the  fifth  or  sixth  year,  pro- 
vided the  disease  has  not  been  arrested,  and  it  would 
seem  that  this  test  is  something  of  an  index  as  to 
the  hardness  of  the  bone.  At  all  events,  I  think 
that  when  one  can  spring  the  bone,  a  trial  of  braces 
should  be  made. 

If  no  improvement  is  obtained  after  a  few  months' 


92  OSTEOTOMY. 

treatment  with  braces  properly  applied  and  cared  for, 
they  are  of  no  use,  and  further  mechanical  treatment 
is  worse  than  useless,  for,  if  braces  do  no  good,  they 
do  harm  by  being  a  useless  incumbrance.  As  stated 
before,  a  patient  with  relaxed  ligaments  is  the  most 
unfavorable  subject  for  any  kind  of  treatment,  but 
especially  mechanical. 

2.  Operative  Treatment. — Section  of  muscles  and 
ligaments  has  been  practiced  for  the  cure  of  genu  val- 
gum, but  with  no  success.  Bonnet,  who  first  advo- 
cated and  performed  section  of  the  tendon  of  the 
biceps,  states  that  "in  no  instance  was  it  followed  by 
success."  It  has  been  performed  by  other  surgeons, 
but  with  no  better  results.  The  danger  of  section  of 
the  popliteal  nerve  should  not  be  forgotten.  Divi- 
sion of  the  external  lateral  ligament,  together  with 
the  tendon  of  the  biceps,  has  had  many  advocates. 
It  has  been  practiced  by  Langenbeck,  Billroth,  and 
others.  Section  of  the  ligament  is  always  followed 
by  lateral  movement  of  the  knee  joint,  and  can  not 
be  an  aid  in  rectifying  the  deformity. 

Mr.  Broadhurst,  who  still  is  an  advocate  of  the 
operation,  exhibited,  at  a  meeting  of  the  Clinical  Soci- 
ety,1 a  patient  on  whom  he  had  made  a  section  of  the 
tendon  of -the  biceps  and  the  external  ligament  of  the 
knee  joint  five  months  previously.  The  patient  was 
unable  to  walk  without  a  splint,  and  there  was  much 
lateral  motion  at  the  knee  joint. 

Mr.  Barwell,  in  some  remarks  on  the  operative 
treatment  of  this  deformity,  states  that  a  section  of 
these  structures  is  worse  than  useless.  Inflammation 
of  the  knee  joint  has  been  known  to  follow  such  an 

i  "  Brit.  Med.  Jour.,"  June  14,  18*79,  p.  897. 


GENU   VALGUM.  93 

operation.  I  had  this  happen  in  a  case  in  which  I 
foolishly  divided  these  structures,  and  ended  in  the 
death  of  the  patient.  Hedressemenl  force,  as  advo- 
cated by  M.  X.  Delore,  as  well  as  osteoclasis,  will  be 
referred  to  in  another  chapter. 

Partial  excision  of  the  knee  joint  has  been  per- 
formed by  Mr.  Annandale,1  resulting  in  a  stiff  knee, 
and  by  Mr.  Howes  for  genu  valgum  due  to  atrophy 
of  the  internal  condyle.2 

1  "Edinb.  Med.  Jour.,"  July,  1875,  p.  18. 

2  "  Guy's  IIosp.  Report,"  1875,  p.  531. 


CHAPTEE  V. 

OSTEOTOMY  FOR  GENU  VALGUM. 

The  earliest  operation  for  the  relief  of  genu  val- 
gum of  which  there  is  any  record  was  performed  by 
Mayer,  of  Wiirzburg,  in  1851.  He  made  a  cunei- 
form osteotomy  of  both  tibiae,  through  an  open  wound, 
with  a  saw.  In  one  limb  the  line  of  incision  healed 
upon  the  sixth  day,  and  firm,  bony  union  was  estab- 
lished on  the  twenty-fourth  day.  He  then  operated 
upon  the  other  limb.  He  accidentally  divided  the 
posterior  tibial  artery  and  vein,  and  the  patient  died 
of  tetanus  on  the  sixty-second  day.  He  operated 
upon  two  other  patients  with  good  results.  Bill- 
roth,'" in  1873,  divided  both  the  tibia  and  fibula  for 
the  relief  of  knock-knee.  Mr.  Annandale2  excised 
the  lower  end  of  the  femur  in  a  case  of  marked  knock- 
knee.  The  patient  was  cured  with  an  anchylosed 
joint.  Schede 3  removed  a  wedge-shaped  piece  from 
the  tibia,  and  divided  the  fibula  with  a  chisel  in  a 
case  of  genu  valgum  with  success.  Ogston,  in  1876, 
separated  the  internal  condyle  from  the  femur,  and, 
sliding  it  up,  brought  the  two  condyles  on  the  same 
plane.  Since  then  several  operations  have  been 
devised  to   accomplish   the   same   end,  which   may 

1  Langenbeck's  "Arch.,"  1875. 

2  "Edinb.  Med  Jour.,"  1875,  p.  18. 
3"Lond.  Med.  Rec,"  June  15,  1877,  p.  24S. 


OSTEOTOMY  FOR   GENU   VALGUM.  95 

be  classed  under  two  heads:  Operations  upon  the 
condyle,  and  operations  upon  the  shaft  of  the  femur 
or  tibia. 

1.  OPERATIONS  UPON  THE  CONDYLE. 

Ogston's  operation  was  to  separate  the  internal 
condyle  from  the  shaft,  and  then  to  slide  it  up  until 
the  two  condyles  were  upon  the  same  plane,  and 
thus  swing  the  tibia  inward.  The  following  is  his 
method  of  performing  the  operation :  After  the  pa- 
tient is  well  under  the  influence  of  an  anaesthetic, 
and  the  limb  rendered  bloodless,  the  leg  is  flexed  on 
the  thigh  as  far  as  possible,  and  the  femur  rotated 
outward.  A  long  tenotomy-knife  is  introduced  three 
and  a  half  inches  above  the  tip  of  the  internal  con- 
dyle, on  the  inner  side  of  the  thigh,  and  so  far  back 
as  to  be  opposite  the  ridge  running  between  the  linea- 
aspera  and  the  condyle.  Its  blade  is  then  carried 
forward,  downward,  and  outward  over  the  front  of 
the  femur,  with  its  cutting-edge  directed  to  the  bone, 
when  its  point  can  be  felt  under  the  skin  in  the 
groove  between  the  condyles,  where  the  patella  would 
normally  have  been  lying  in  the  extended  position  of 
the  limb,  the  cutting-edge  is  pressed  against  the  bone, 
and  the  soft  parts  divided  with  a  slow  movement 
in  withdrawing  the  knife.  The  external  wound  thus 
made  should  be  about  one  third  of  an  inch  long,  and 
form  the  entrance  to  a  subcutaneous  tunnel  running 
obliquely  over  the  front  of  the  femur  and  end- 
ing in  the  cavity  of  the  joint.  An  Adams's  saw  is 
then  introduced  into  the  tunnel,  and  the  condyle 
sawn  off  by  directing  the  edge  of  the  instrument 
straight  backward.     When  it  is  estimated  that  the 


96 


OSTEOTOMY. 


edge  of  the  saw  lias  arrived  near  the  popliteal  space 
it  is  withdrawn,  the  knee  completely  extended,  and 
with  the  hands,  and  the  operator's  knee  as  a  ful- 
crum, the  patient's  knee  is  then  forcibly  straightened 
by  bending  the  leg  inward,  the  remaining  connections 
of  the  condyle  with  the  femur  giving  way  with  a 
crack  on  the  application  of  very  moderate  force,  and 
instantly  the  leg  becomes  straight.  The  whole  opera- 
tion is  done  under  strict  antiseptic  rules  (Lister),  and 
the  limb  put  up  in  splints  in  a  corrected  position. 
Fig.  2 1  rejjresents  the  line  of  Ogston's  section. 

Reeves1  modified  Ogston's  operation  by  making 
the  section  with  an  osteotome  in  the  following  man- 
ner: 

A  scalpel,  previously  dipped  in  carbolized  oil,  is 
introduced  obliquely  just  above 
the  tubercle  for  the  attachment 
of  the  tendon  of  the  adductor 
magnus,  and  the  soft  parts  and 
periosteum  are  divided  in  the 
line  of  the  Ogston's  section,  the 
length  of  the  wound  in  the  soft 
parts  being  long  enough  to  easily 
admit  the  osteotome.  This  in- 
strument is  then  introduced,  and, 
commencing  on  the  ridge  of  bone 
going  from  the  tubercle  for  the 
attachment  of  the  tendon  of  the 
adductor  magnus  to  the  linea 
aspera,  is  driven  downward  and 
outward  toward  the  inter-condyloid  notch ;  the 
bone  being  divided  only  as  far  as  the  cartilage  on 

1  "Brit.  Med.  Jour.,"  May  25,  18*78. 


Fig.  21. 


OSTEOTOMY  FOR   GENU   VALGUM. 


97 


its  articular  surface.  The  condyle  is  then  loosened 
by  nsing  the  chisel  as  a  lever,  and  is  separated  com- 
pletely by  forcibly  straightening  the  limb,  which  is 
at  once  put  up  in  a  permanent  dressing.  Fig.  22 
shows  the  extent  of  the  cut  in  the  bone  in  Reeves's 
operation.  He  claims  that  by  this  method  the  joint 
is  not  entered  either  by  the  chisel  or  in  forcibly  slid- 
ing the  condyle  up,  the  cartilage  being  bent  to  ac- 
commodate itself  to  the  new  position  of  the  condyle. 
It  maybe  possible  in  a  few  cases  to  prevent  the  osteo- 
tome from  entering  the  joint,  but,  in  sliding  the  con- 
dyle up,  the  cartilage  is  lacerated  and  the  joint  thus 
opened. 

Another  operation,  having  in  view  the  raising  of 
the  plane  of  the  internal  condyle,  is  described  in 
the  "Edinburgh  Medical  Jour- 
nal," 1879,  p.  881,  by  Mr.  Chiene, 
as  follows:  "Find  the  tubercle 
on  the  internal  condyle  to  which 
the  long  tendon  of  the  adduc- 
tor magnus  is  attached.  An  in- 
cision two  or  three  inches  in 
length  is  made  over  the  tubercle 
in  the  long  axis  of  the  limb  ;  the 
incision  commences  half  an  inch 
below  the  tubercle,  and  is  car- 
ried upward  for  a  sufficient  dis- 
tance. After  the  division  of 
the  skin  and  the  fascia,  the  tendon  of  the  ad- 
ductor magnus  is  exposed.  Pass  in  front  of  the 
tendon,  between  it  and  the  fibers  of  the  vastus 
internus.  The  bone  covered  by  periosteum  is  ex- 
posed, and  the  superior-articular  artery  is  seen  and 


Fig.  22. 


98 


OSTEOTOMY. 


divided,  after  passing  a  double  ligature  below  it 
and  tying  the  vessel.  The  periosteum  is  then  cruci- 
ally incised  and  turned  aside,  exposing  the  bone. 
With  a  chisel  and  mallet  a  wedge-shaped  portion  of 
bone  is  removed  from  the  base  of  the  condyle,  imme- 
diately above  the  tubercle  of  attachment  of  the  ad- 
ductor magnus.  The  breadth  of  the  wedge  will  de- 
pend on  the  amount  of  the  deformity.  The  long 
axis  of  the  wedge  runs  downward  and  outward 
toward  the  notch  between  the  condyles.  The  wedge 
is  at  a  higher  level  than  the  epiphyseal  line.'1     He 


Fig.  23. 


Fig.  24. 


then  bends  the  lower  portion  so  as  to  displace  the 
condyle  upward.  Fig.  23  shows  the  extent  and  posi- 
tion of  the  wedge  removed  in  Chiene's  operation. 

Macewen  performed  an  operation  somewhat  simi- 
lar to  that  of  Chiene,  except  that  he  removed  the 
wedge  in  Ogston's  line,  and  then,  folding  up  as  it 
were  the  internal  condyle,  corrected  the  deformity. 
Fig.  24  represents  Mace  wen's  first  operation. 


OSTEOTOMY  FOE   GENU   VALGUM.  99 

Schmitz,1  of  St.  Petersburg,  performed  an 
Ogston's  operation  through  a  large  wound,  claim- 
ing as  an  advantage  that  he  could  see  what  he 
was  doing. 

All  of  these  operations  have  one  thing  in  common, 
namely,  operating  upon  the  internal  condyle.  Og- 
ston's seems  the  most  dangerous,  on  theoretical 
grounds,  in  that  the  joint  is  directly  opened,  yet  in- 
flammation has  rarely  followed  it,  and  out  of  the  num- 
ber operated  upon  failures  have  been  ver}^  few,  and  a 
fatal  issue  has  been  exceptional.  In  most  of  the  cases 
there  has  been  effusion  of  blood  into  the  joint.  A 
case  of  suppuration  has  been  reported,  but  the  pus 
was  outside  of  the  joint.  There  has  been  one  case  of 
ankylosis  at  a  right  angle,  but  neither  necrosis  nor 
inflammation  of  the  bone  has  ever  been  reported. 
The  object  aimed  at  by  either  an  Ogston's  or  Reeves's 
operation  is  to  separate  the  internal  condyle  from  the 
shaft,  and  then  to  slide  it  up  so  that  its  lower  surface 
shall  occupy  a  higher  plane,  and  thus  carry  the  long 
axis  of  the  tibia  inward  and  correct  the  deformity.  In 
neither  of  these  operations  are  the  ligaments  divided 
or  weakened.  In  some  few  cases  over-correction  has 
been  made,  and  a  genu  varum  has  resulted.  In 
Reeves's  operation  the  joint  is  certainly  not  entered 
by  the  chisel  in  some  cases,  although  it  is  broken 
into  in  all.  On  anatomical  grounds,  these  operations 
are  correct  in  those  cases  in  which  the  defect  lies 
entirely  in  the  internal  condyle.  After  correcting  the 
deformity  there  remains  a  re-entering  angle  on  the 
lower  surface  of  the  articular  end  of  the  femur.  This 
in  time  is  filled  up  partly  by  osseous  material  and 

1  "  Centralblatt  f.  Chir.,"  April,  1879. 


100  OSTEOTOMY. 

partly  by  connective  tissue  derived  from  the  serous 
surface  of  the  condyle  (Thiersch). 

An  objection  was  raised  by  Thiersch,  at  the 
seventh  congress  of  German  surgeons,  held  in  1878, 

O  O  7  7 

to  Ogston's  operation  for  genu  valgum,  in  that  he 
feared  the  interruption  of  the  epiphyseal  cartilage 
might  easily  interfere  with  the  growth  of  .that  por- 
tion of  the  bone.1  I  am  not  aware  of  any  case  in 
which  this  result  has  been  reported.  Recently, 
through  the  kindness  of  my  friend,  Dr.  F.  Lange,  I 
have  had  the  opportunity  to  examine  a  case  in  which 
atrophy  or  arrest  of  development  has  occurred  after 
an  Ogston's  operation.  The  patient  is  a  healthy- 
looking  girl,  eight  years  of  age,  on  whom,  in  1878, 
when  two  years  old,  an  Ogston's  operation  was  per- 
formed for  unilateral  genu  valgum  of  the  left  limb. 
For  two  years  nothing  abnormal  was  noticed,  but  at 
the  end  of  that  date  the  left  knee  began  to  bend  out- 
ward,  and  walking  became  difficult. 

This  outward  displacement  continued  to  increase, 
and  with  it  the  embarrassment  in  getting  about. 
There  has  been  no  pain  about  the  knee  joint.  On 
examination,  there  is  found  to  exist  a  marked  genu 
varum  on  the  left  side  when  the  leg  is  extended 
which  disappears  on  flexion.  The  joint  looks  broad- 
er than  the  right,  and  measures  one  inch  more  in 
circumference  than  the  other.  The  anterior  surface 
of  the  external  condyle  is  prominent,  owing  to  a 
displacement  of  the  patella  inward.  The  internal 
condyle  is  much  smaller  than  the  corresponding 
one  of  the  right  limb,  and  its  lower  border  is  on  a 
plane  an  inch  higher  than  that  of  the  external,  and 

1  "London  Med.  Record,"  June  15,  1578,  p.  269. 


OSTEOTOMY  FOR   GENU   VALGUM.  101 

tliere  is  a  corresponding  loss  of  substance  on  the 
inner  side  of  the  femur,  in  the  location  where  the 
internal  condyle  should  be  in  the  normal  limb;  its 
anterior  aspect  is  also  more  posterior.  It  is  felt  as 
an  oblong  excrescence  on  the  shaft  of  the  bone,  and  is 
much  smaller  in  all  its  diameters  than  the  one  in  the 
corresponding  limb.  It  evidently  has  not  kept  pace 
in  its  growth  with  the  rest  of  the  bone,  if  indeed  it 
has  grown  at  all.  The  space  left  by  the  change  in 
the  plane  of  the  condyle  is  occupied  in  front  by  the 
patella,  which  is  dislocated  inward  and  does  not 
leave  its  abnormal  position  in  any  motion  of  the  leg. 
The  inner  head  of  the  tibia  has  increased  in  height 
more  than  its  external,  so  that  it  partially  occupies, 
in  the  extended  position,  the  gap  left  at  the  lower 
end  of  the  femur.  The  operation-wound  is  repre- 
sented by  a  slight  cicatrix.  The  increase  in  the  cir- 
cumference of  the  knee  is  due  to  the  displacement  of 
the  patella. 

From  this  description  it  is  evident  that  the  opera- 
tion, by  cutting  through  the  epiphyseal  cartilage,  has 
seriously  interfered,  if  it  has  not  entirely  arrested, 
the  growth  of  the  internal  condyle,  and  has  left  the 
patient  in  a  much  worse  condition  than  if  the  opera- 
tion had  not  been  performed.  This  case  exhibits  a 
fatal  defect  in  Ogston's  operation  upon  patients  who 
have  not  attained  their  full  growth.  And  the  same 
remark  is  applicable  to  all  operations  upon  the  con- 
dyle that  in  any  way  interferes  with  the  epiphyseal 
cartilage. 

"Reeves's  is  a  difficult  operation  to  perform.  The 
section  has  to  be  made  slowly,  and  you  are  near 
important  vessels.     If  the  ligaments  are  relaxed  or 


1 02  OSTEOTOMY. 

weakened  so  that  they  stretch,  it  is  veiy  difficult 
to  slide  the  partially  detached  condyle  up.  In  two 
cases  I  failed  to  correct  the  deformity  from  this 
cause.  It,  however,  has  this  advantage :  that  recov- 
eries are  much  more  rapid  than  after  any  other 
operation. 

Both  Macewen's  and  Chiene's  cuneiform  osteoto- 
mies at  the  internal  condyle  were  successful.  They 
are  difficult  operations  to,  perform,  and  they  have  the 
disadvantage  of  being  done  through  an  open  wound. 
They  have  not  been  repeated  by  any  other  operators. 

2.    OPERATIONS    OlST    THE    SHAFT. 

In  1877,  Mace  wen  corrected  a  case  of  genu  valgum 
by  making  a  transverse  section  of  the  shaft  of  the 
femur  from  the  inside,  a  short  distance  above  the 
epiphyseal  line  of  that  bone,  in  the  following  manner : 
After  rendering  the  limb  bloodless,  with  a  sharp- 
pointed  knife  an  incision  was  made  at  a  point 
where  the  two  following  lines  meet — one  drawn  trans- 
versely a  finger's  breadth  above  the  superior  tip  of 
the  external  condyle,  and  a  longitudinal  one  drawn 
half  an  inch  in  front  of  the  adductor-magnus  tendon. 
This  line  of  division  is  above  the  epiphyseal  carti- 
lage. Fig.  25  shows  the  line  of  section  in  Macewen's 
second  operation. 

Mr.  Barwell,  acting  upon  the  theory  that  knock- 
knee  is  a  deformity  due  always  to  changes  in  the 
femur  and  tibia,  makes  a  section  above  the  epiphy- 
seal line  of  the  femur,  and  corrects  one  half  of  the 
deformity.  Two  weeks  later  he  divides  the  tibia  and 
fibula  near  the  knee  joint  and  corrects  the  other  half, 


OSTEOTOMY  FOB   GENU  VALGUM. 


103 


thus  performing  three  osteotomies.  He  certainly  ob- 
tains no  better  results  than  Macewen  does  by  a 
single  section.  In  some  cases, 
however,  of  very  marked  genu 
valgum,  a  femoral  section  does 
not  correct  enough,  and  then  a 
section  of  the  tibia  should  be 
done;  but,  as  a  rule,  there  is  no 
necessity  of  performing  more 
than  one  osteotomy,  and  when 
there  is  no  necessity  it  is  worse 
than  useless. 

MacCormac1  advocates  sec- 
tion from  the  outside,  making 
the    division    just    above    and  FlG  25 

parallel  to  the  articular  surface. 
He  penetrates  the  bone  to  three  fourths  of  its  thick- 
ness and   then  fractures.      Dr.  E.  H.  Bradford,  of 
Boston,  has   repeated   MacCormac's   operation,  and 
speaks  well  of  it.2 

Taylor3  divided  the  shaft  of  the  femur  from  the 
outside  a  hand's  breadth  above  the  joint.  This  opera- 
tion is  evidently  only  applicable  to  cases  of  genu  val- 
gum due  to  femoral  curves. 

Reeves 4  advocates  the  division  of  the  femur  just 
below  its  middle,  and  states  that  he  has  performed 
this  operation  seven  times.  He  calls  it  mid-femoral 
osteotomy.  Its  advantages,  he  thinks,  are:  First, 
the  bone  is  divided  nearly  at  its  smallest  part ;  there- 
fore, Second,  the  operation   is   more   quickly  done. 

1  "Antiseptic  Surgery,"  p.  1S9. 

2  "New  York  Med.  Jour.,"  January,  1881,  p.  26. 

3  "  Brit.  Med.  Jour.,"  April  7,  1877,  p.  429. 

4  "  Brit.  Med.  Jour.,"  December  10,  1881,  p.  935. 

8 


104  OSTEOTOMY. 

Third,  the  deformity  is  readily  corrected,  and  the 
large  callus  which  forms  when  supra-condyloid  oste- 
otomy is  performed  is  avoided.  Fourth,  the  effusion 
into  the  joint,  which  sometimes  follows  the  supra-con- 
dyloid operation,  is  avoided.  Fifth,  recovery  is  quick- 
er. Sixth,  multiple  osteotomies  are  done  away  with, 
All  these  operations  upon  the  shaft  are  above  the 
epiphyseal  cartilage,  and  at  such  a  distance  from  the 
joint  that  the  articulation  is  not  entered  by  the  chisel, 
and  seldom  fractured  into  in  straightening  the  limb. 
Sections  above  Macewen's  line  are  seldom  made. 
They  are  applicable  only  to  those  cases  of  genu  val- 
gum due  to  femoral  curves,  and  even  in  this  class  it 
is  not  often  that  the  deformity  is  due  to  this  cause 
alone,  overgrowth  of  the  bone  just  above  the  internal 
condyle,  or  changes  in  the  condyle  itself,  being  super- 
added. Division  just  above  the  epiphysis  is  applica- 
ble to  all  cases  of  knock-knee  dependent  on  femoral 
changes,  whether  the  section  is  made  from  within 
outward  (Macewen),  or  from  without  inward  (Mac- 
Cormac).  It  is  true  that  in  the  former  the  limb  is 
slightly  shortened,  while  in  the  latter  it  is  lengthened, 
but  the  difference  is  too  little  to  be  taken  into  ac- 
count, provided  the  same  operation  is  performed  on 
both  limbs.  Reeves's  objection  to  the  supra-condy- 
loid operation,  in  that  the  joint  is  at  times  affected,  I 
think  of  little  moment.  Effusion  into  the  articula- 
tion is  very  seldom  seen,  and,  when  it  does  exist,  is 
soon  absorbed.  Mid-femoral  operations  are  applica- 
ble to  but  few  cases.  The  presence  of  a  large  callus 
is  exceptional  in  my  experience,  and  the  time  neces- 
sary for  firm  bony  union  to  take  place  is  the  same 
in  both  cases. 


OSTEOTOMY  FOR   GENU   VALGUM.  105 

But  few  operators  have  adopted  either  Taylor's 
or  Reeves's  mid-femoral  line  of  section.  The  ma- 
jority make  the  division  just  above  the  epiphysis. 

Of  the  operations  for  the  correction  of  genu  val- 
gum, that  devised  by  Macewen  has  superseded  all 
others.  It  is  easier  to  perform,  is  applicable  to  all 
cases,  is  so  far  removed  from  the  joint  that  there  is 
no  danger  of  injury  to  it  or  its  ligaments,  and  at  the 
same  time  is  near,  if  not  directly,  at  the  point  of  ab- 
normal deviation. 

I  have  had  experience  with  but  one  other,  and 
that  is  Reeves's  section  in  Ogston's  line. 

Macewen's  supra-con clyloid  operation  may  be  per- 
formed in  the  following  manner:  The  patient  having 
been  etherized,  an  Esmarch's  bandage  is  applied,  ex- 
tending well  up  on  the  thigh  so  as  to  be  entirely  out 
of  the  way  during  the  operation.  The  leg  is  fully 
flexed  on  the  femur,  the  thigh  rotated  outward,  so  as 
to  give  easy  access  to  its  inner  portion  just  above 
the  knee  joint,  and  the  limb  is  laid  on  a  sand  pillow, 
which  has  been  molded  to  the  knee  and  lower  por- 
tion of  the  thigh,  so  as  to  give  a  firm  bed  for  its 
support  during  the  operation. 

An  incision  is  then  made  down  on  the  ridge 
of  bone  running  from  the  tubercle  for  the  attach- 
ment of  the  tendon  of  the  adductor  magnus  to  the 
linea  aspera,  at  a  point  a  finger's  breadth  above  a 
line  drawn  inward  from  the  lip  of  the  external  con- 
dyle. The  incision  should  be  made  parallel  to  the 
long  axis  of  the  limb,  and  a  little  longer  than  the 
width  of  the  largest  instrument.  Keeping  the  knife 
in  position,  the  largest  osteotome  is  then  passed 
down  on  it  as  a  guide,  and,  when  on  the  ridge  of 


106  OSTEOTOMY. 

bone,  the  knife  is  withdrawn  and  the  instrnment  ro- 
tated so  that  the  cutting-edge  is  at  right  angles  to  the 
line  of  incision.  It  is  better  to  begin  the  section 
from  this  point,  directing  the  osteotome  outward  and 
forward,  for  by  so  doing  the  inner  and  posterior- 
lateral  portions  of  the  femur  are  divided  first,  and  you 
are  working  away  from  the  vessels.  After  the  com- 
pact tissue  of  the  femur  has  been  divided,  the  prog- 
ress of  the  osteotome  through  the  central  portion  of 
the  bone  will  be  more  rapid  until  the  external  shell 
is  reached.  This  will  be  readily  known  by  the 
greater  resistance  offered  to  the  instrument.  If  the 
osteotome  becomes  wedged,  it  should  be  replaced 
with  the  next  smaller.  After  the  bone  has  been  di- 
vided on  its  inner  anterior  and  posterior  aspect,  and 
the  instrument  has  penetrated  into  the  compact  bony 
tissue  on  the  external  aspect  of  the  femur,  the  osteo- 
tome is  withdrawn  and  the  leg  extended  on  the 
thigh,  the  wound  having  been  covered  with  a  sponge 
wet  with  carbolized  water.  Then  grasping  the  lower 
portion  of  the  femur  just  above  the  point  of  section 
with  one  hand,  and  the  leg  with  the  other,  using  the 
latter  as  a  lever,  the  remaining  portion  of  the  femur 
is  fractured.  The  wound  should  be  treated  in  the 
manner  mentioned  on  page  22.  After  placing  a  com- 
press over  the  wound,  the  whole  limb,  from  the 
toes  as  far  up  on  the  thigh  as  possible,  is  bandaged 
with  a  flannel  roller,  and  over  this  plaster-of-Paris 
bandages  placed.  Before  the  latter  sets,  the  leg  is 
to  be  carried  inward,  so  as  to  bring  it  a  little  beyond 
the  long  axis  of  the  femur ;  or,  in  other  words,  to  over- 
correct  the  deformity.  Care  should  be  taken  to  keep 
the  leg  well  extended  on  the  thigh  while  the  plaster 


OSTEOTOMY  FOR   GENU   VALGUM.  107 

is  hardening.  In  order  to  keep  the  limb  in  position 
while  the  plaster  is  drying,  it  is  an  advantage  to 
place  a  roll  of  flannel,  about  four  inches  in  diameter 
covered  with  rubber  cloth,  between  the  thighs  above 
the  point  of  fracture,  and,  using  it  as  a  fulcrum,  to 
bend  the  two  legs  together  and  tie  them.  The  feet 
should  rest  on  a  pillow,  in  order  that  the  knees  do 
not  become  flexed.  Care  should  be  taken  that  the  two 
fragments  are  in  such  a  position  that  there  may  be  no 
lateral  displacement.  In  one  case  I  have  seen  a  slid- 
ing backward  of  the  lower  fragment,  but  not  enough 
to  cause  any  trouble,  yet  it  is  well  to  avoid  this.  After 
the  splint  has  well  hardened,  the  patient  is  returned  to 
the  bed  and  the  limbs  suspended  bypassing  a  bandage 
under  the  middle  of  the  les;  and  over  the  bed  cradle, 
or  any  suitable  apparatus  that  may  be  at  hand  can 
be  used.  Suspension  seems  to  give  comfort.  On  the 
third  day  the  wound  is  examined,  the  splint  is  left  on 
for  four  weeks,  when  it  is  removed  and  the  patient 
allowed  to  use  his  limbs,  and,  if  the  union  seems 
firm,  to  go  about. 

The  operation  described  above  varies  from  that  of 
Mace  wen  in  three  particulars :  1st.  In  the  omission  of 
Listerism ;  2d.  In  the  position  of  the  limb  during  the 
operation  ;  and,  3d.  In  the  method  of  treating  the 
wound.  The  reasons  for  the  first  and  third  varia- 
tions have  been  given  when  describing  the  operation 
of  osteotomy,  page  24.  The  reasons  for  the  sec- 
ond are  as  follows :  Macewen  operates  with  the  limb 
fully  extended1  and  rotated  outward,,  and  makes  his 
incision  where  the  two  following  lines  bisect  one 
another — a  line  drawn  transversely  a  finger's  breadth 

1  "Lancet,  "  December  28,  1878,  p.  911. 


108  OSTEOTOMY. 

above  tlie  level  of  the  upper  border  of  the  external 
condyle,  and  a  line  drawn  parallel  to  and  half  an  inch 
in  front  of  the  tendon  of  the  adductor  rnagnus.  This 
line,  Macewen  states,  is  below  and  anterior  to  the  an- 
astomatica  magna,  and  above  the  superior  articular. 

It  is  much  easier  to  get  at  the  inner  aspect  of  the 
thigh  with  the  leg  flexed  than  when  it  is  extended. 
The  ridge  of  bone  running  from  the  tubercle  for 
the  attachment  of  the  tendon  of  the  adductor  rnag- 
nus to  the  linea  aspera  is  a  much  more  certain  guide 
than  a  line  half  an  inch  in  front  of  that  tendon.  This 
ridge  is  very  easy  to  find,  and,  with  the  leg  flexed, 
there  is  no  difficulty  in  cutting  down  upon  it.  An- 
other advantage  in  operating  with  the  knee  bent  is 
that  when  the  leg  is  extended  the  skin  and  sub- 
cutaneous tissue  slides  downward  and  forward,  and 
thus  closes  over  the  wound  in  the  muscles.  I  think 
also  that  a  firmer  support  for  the  limb  is  obtained 
Avhen  the  leg  is  flexed. 

G.  C.  Wright,1  surgeon  to  the  General  Hospital 
for  Sick  Children,  Manchester,  makes  a  section  with 
a  saw  from  outside,  on  a  line  above  the  adductor 
tubercle. 

CASES    APPEOPEIATE    FOE    OSTEOTOMY. 

Infantile  Cases. — These  may  be  considered  under 
two  classes — those  in  which  the  bones  have  become 
hardened,  and  those  in  which  the  process  of  sclerosis 
is  still  going  on. 

I.  There  can  be  no  doubt  as  to  the  necessity  of 
an   osteotomy   to  correct  a  genu  valgum  after   the 

1  "  Abstracts  of  Medical  and  Surgical  Cases  treated  at  the  General  Hospital 
for  Sick  Children,"  Manchester,  1882. 


OSTEOTOMY  FOR   GENU   VALGUM.  109 

bones  have  become  hard.  The  question  as  to  the 
date  at  which  this  condition  has  been  reached  is 
much  more  difficult  to  answer;  and,  as  said  before, 
it  is  not  a  question  of  age,  but  of  nutrition.  Thus, 
I  lately  performed  an  osteotomy  for  unilateral  knock- 
knee  on  a  child  three  years  of  age.  She  had  been 
under  good  mechanical  treatment  for  six  months  with- 
out the  slightest  effect  on  the  deformity.  In  making 
the  section,  the  femur  was  found  to  be  very  hard  and 
very  difficult  to  divide.  Again,  on  doing  a  supra- 
condyloid  operation  on  a  boy  eight  years  of  age,  the 
bones  were  quite  soft.  If  the  deformity  had  been 
uncomplicated,  I  have  no  doubt  it  could  have  been 
corrected  with  splints.  I  do  not  see  how  any  fixed 
rule  can  be  laid  down  as  to  the  age  at  which  an 
osteotomy  should  or  should  not  be  performed.  It 
would  seem,  however,  that  if,  after  several  months 
of  careful  mechanical  treatment,  there  has  been  no 
improvement,  any  further  use  of  braces  is  worse 
than  useless,  for  if  they  do  no  good,  they  are  cer- 
tain to  do  harm.  They  cause  atrophy  of  the  limb, 
are  a  hindrance  to  locomotion,  and  a  constant  cause 
of  care  and  expense. 

In  regard  to  the  condition  of  the  bone,  the  state 
of  the  tibia  has  seemed  to  be  something  of  a  guide. 

If  by  the  use  of  moderate  force  (and  by  moderate 
is  meant  not  enough  to  cause  any  pain)  the  bone  is 
felt  to  yield  or  spring,  it  is  safe  to  conclude  that  the 
bone  has  not  become  hard.  It  is,  however,  to  be  re- 
membered that  the  intensity  of  the  rachitic  process 
falls  upon  different  bones  in  different  degrees,  and 
that  the  condensation  process  is  often  very  much 
further   advanced  in   one  bone  than  in  another  in 


HO  OSTEOTOMY. 

the  same  individual.  If  the  bone  does  not  yield, 
the  sclerosis  has  advanced  so  far  that  mechanical 
treatment  will  fail  as  a  rule. 

There  is  another  condition  which  complicates 
both  mechanical  and  operative  treatment,  but  the 
former  more  than  the  latter,  and  that  is  a  relaxa- 
tion of  the  ligaments.  A  child  with  weak,  but  not 
relaxed,  ligaments  is  not  a  good  subject  for  mechani- 
cal treatment.  In  healthy  children  braces  will  fail 
to  correct  a  case  of  genu  valgum  after  the  fourth  or 
fifth  year.  I  think  that  the  practice  of  compelling 
children  to  wear  mechanical  appliances  for  the  relief 
of  knock-knee  for  years  is  cruel,  and  should  be  con- 
demned. By  early  recognizing  which  cases  are  ap- 
propriate for  mechanical  treatment  and  those  which 
are  not,  much  time  can  be  saved.  I  think  that  a  re- 
laxed ligament  is  an  argument  in  favor  of  an  early 
operation. 

II.  Those  cases  in  which  the  bones  have  become 
only  partially  sclerosed. 

Some  of  these  cases,  perhaps  the  majority,  occur- 
ring in  children  at  or  about  the  fourth  year  can  be 
corrected  by  mechanical  appliances,  if  the  external 
lateral  ligament  is  strong.  Yet  in  practice  it  is  not 
often  accomplished.  The  vast  majority  of  cases  of 
knock-knee  are  children  of  the  poorer  classes,  among 
whom  it  is  almost  impossible  to  have  an  instrument 
properly  applied  and  cared  for.  They  have  not  the 
time,  and  often  not  the  intelligence,  to  give  their  chil- 
dren proper  attention.  In  proof  of  this,  reference  is 
again  made  to  the  statistics  given  on  page  90.  Out 
of  fifty-seven  children  under  five  years  of  age  affected 
with  knock-knee,  only  thirteen  were  discharged  cured, 


OSTEOTOMY  FOR   GENU   VALGUM.  Hi 

and  this  at  a  dispensary  distinguished  for  the  care 
and  attention  given  to  its  patients.  It  is  a  question, 
therefore,  whether  the  majority  of  children  in  good 
health,  over  four  years  of  age,  would  not  be  enabled 
to  walk  sooner  by  an  operation,  and  whether  more 
children  would  not  be  permanently  cured  in  early 
life  by  this  means  than  by  being  submitted  to  me- 
chanical treatment  ?  I  must  confess  that  my  own 
feelings  are  decidedly  in  favor  of  an  operation. 

Properly  performed,  osteotomy  is  not  a  serious 
operation.  It  is  not  only  justifiable,  but  is  for  the 
best  interests  of  this  class  of  patients.  In  knock-knee 
occurring  among  the  better  classes,  I  think  that  a  fair 
trial  of  splints  should  be  made  in  healthy-looking 
children  under  four  or  five  years  of  age.  If  they  fail, 
an  osteotomy  should  be  done. 

In  cases  of  genu  valgum  adolescentium  the  same 
rules  apply  in  regard  to  their  management  as  in  the 
deformity  occurring  in  children.  It  can  be  corrected 
by  apparatus  before  the  bone  has  become  consoli- 
dated. After  that  by  an  osteotomy.  The  deformity 
is  of  rapid  formation,  and  the  bone  soon  becomes  hard, 
so  that  mechanical  treatment,  to' be  efficacious,  must 
be  begun  early. 

The  result  on  the  bone  at  the  point  of  division  is  to 
cause  a  condensation  of  the  osseous  structure  on  either 
side  of  the  osteotome,  and  thus  form  a  wedge-shaped 
cut  into  that  tissue.  Dr.  A.  T.  Cabot x  has  recorded 
the  post-mortem  appearance  of  the  bone  at  the  point 
of  section  after  a  Macewen  operation  (Plate  V),  the 
j>atient  dying,  six  weeks  after  section,  of  typhoid  fever. 
He  says :  "  In  this  figure  the  inner  side  of  the  bone 

1  "Boston  Med.  and  Surg.  Jour.,"  February  16,  1883,  p.  154. 


112  OSTEOTOMY. 

upon  which  the  chisel  was  entered  is  to  the  right.  At 
c  we  have  the  line  of  the  epiphysis;  three  fourths 
of  an  inch  above  this  is  the  line  of  division.  On 
the  outer  side  of  the  bone  the  line  of  the  shaft  is 
pretty  well  preserved.  On  the  inner  side  a  consider- 
able displacement  has  occurred.  The  compact  wall 
of  the  shaft  has  been  driven  down  into  the  cancel- 
lated tissue  at  the  point  a.  The  tissue  in  the  middle 
of  the  shaft,  on  the  other  hand,  was  less  resistant 
than  the  more  densely  cancellated  tissue  below,  so 
that  the  center  of  the  lower  fragment  is  impacted 
into  the  upper.  A  very  firm  locking  is  the  conse- 
quence, and  this,  no  doubt,  greatly  facilitated  rapid 
recovery.  That  there  has  been  but  slight  reaction  in 
the  parts  above  is  shown  by  the  absence  of  callus. 
The  only  true  callus  formation  is  seen  at  bt  where  a 
little  new  bone  has  been  thrown  out  over  the  free  end 
of  the  lower  fragment ;  besides  this  there  is  only  a 
very  thin  layer  of  new  bone  under  the  periosteum 
on  the  outer  side."  1 

Results. — As  to  the  limb.  The  object  of  a  subcon- 
dyloid  (Mace wen's)  operation  is  to  make  a  wedge- 
shaped  incision  into  the  lower  end  of  the  femur,  just 
above  the  epiphysis,  extending  from  within  outward, 
the  apex  of  the  wedge  penetrating  the  compact  os- 
seous structure  on  the  outer  aspect  of  the  bone.  By 
the  use  of  the  largest  osteotome  at  the  beginning,  and 
only  replacing  it  with  the  next  smaller  when  it  is  ab- 
solutely necessary,  on  account  of  the  instrument  be- 
coming wedged,  the  cut  in  the  bone  is  made  wider, 
not  by  any  loss  of  substance,  but  by  condensation  of 
the  bone  on  either  side  the  instrument.     In  cases  of 

1  "Boston  Med.  and  Surg.  Jour.,"  1882,  vol.  cvi,  p.  155. 


PLATE   V. 


Dr.  A.  T.  Cabot's  case— the  parts  after  a  supra-condyloid  operation. 


OSTEOTOMY  FOR   GENU   VALGUM.  113 

knock-knee  where  the  deformity  is  not  very  great,  in 
bending  the  leg  inward  the  two  opposite  surfaces  of 
this  V-shaped  cut  come  into  apposition,  and  just  cor- 
rect the  malposition  of  the  leg.  ~No  re-entering  angle 
is  left  on  the  outer  aspect  of  the  femur.  If,  however, 
the  deformity  is  great,  there  will  exist  a  re-entering 
angle  opposite  the  point  of  section  on  the  external 
aspect  of  the  bone.  This,  as  has  been  proved  by  post- 
mortem examination,  will  till  up  with  new  bone,  the 
same  as  after  a  simple  fracture.  The  effect  on  the 
bone,  as  a  whole,  is  to  compensate  for  the  curve 
with  its  convexity  inward,  by  a  sharp  bend  hav- 
ing  its    angle   at    the  lower  end  of  the  bone.     In 


Fig.  26.  Fig.  27. 

those  cases  where  the  deformity  is  due  to  a  change 
in  the  shape  of  the  condyle,  where  it  is  depressed 
either  by  growth  or  by  the  abnormal  deposit  of  bone 
just  above  it,  the  result  of  the  operation  is  practically 
to  remove  a  wedge-shaped  piece  of  bone,  and  thus 
raise  the  plane  of  the  condyle.  That  there  is  an 
actual  change  in  the  plane  of  the  two  condyles  after 
a  supra-con dyloid  operation  is  demonstrated  in  Figs. 
26  and  27.     They  are  reduced  from  tracings  of  the 


114  OSTEOTOMY. 

lower  end  of  the  femur  before  and  after  the  opera- 
tion. The  cut  marked  E  is  from  the  right,  that 
marked  L  from  the  left  limb;  the  star  indicates  the 
internal  condyle,  the  heavy  line  the  contour  of  the 
parts  before,  the  dotted  line  after  the  section.  It 
will  be  noticed  that  the  two  condyles  after  the  op- 
eration are  upon  the  same  plane.  The  distance  be- 
tween the  two  lines  is  the  amount  of  correction 
gained  by  the  operation.  It  is  true  that  the  cor- 
rection in  some  cases  is  not  at  the  real  point  of  de- 
formity, yet  practically  it  is  perfect  as  far  as  the  posi- 
tion of  the  tibia  is  concerned,  and  this  is  the  real 
deformity. 

Suppuration. — In  a  carefully  performed  osteoto- 
my, suppuration  of  any  amount  is  rarely  met.  In 
my  own  experience,  after  a  supra-con dyloid  operation, 
suppuration  has  occurred  in  four  limbs  only.  In 
three  it  evidently  had  its  starting-point  in  a  piece  of 
tissue  that  protruded  from  between  the  lips  of  the 
wound,  and  was  irritated  by  the  dressing.  On  re- 
moving the  compress  from  over  the  wound,  the  pus 
flowed  out,  proving  that  the  pad,  hardened  with 
blood,  prevented  its  escape.  The  application  of  a 
large  compress  in  the  course  of  the  abscess  was  soon 
followed  by  a  cure.  The  other  abscess  I  can  assign 
no  cause  for.  It  was  small,  and  gave  no  trouble.  In 
two  of  these  cases  the  thermometer  gave  no  indica- 
tion of  the  presence  of  matter,  the  temperature  being 
normal  the  whole  time. 

STATISTICS. 

Of  six  hundred  and  twenty-two  cases  of  Mac- 
e wen's  operations  (section  above  the  condyles),  as 


OSTEOTOMY  FOR   GENU   VALGUM.  H5 

far  as  can  be  ascertained,  there  have  been  but  three 
fatal  cases  reported  that  could  in  any  way  be  at- 
tributed to  the  operation.  One  was  a  case  reported 
by  Dunlap,  where  death  was  due  to  septicaemia  sec- 
ondary to  a  cellulitis  of  the  thigh  due  to  improper 
dressing;  one,  by  Bull,  was  probably  the  result  of 
carbolic-acid  poisoning.  Langton '  reports  a  case  in 
which  he  performed  a  Macewen's  operation  on  the 
right  femur  of  a  patient  nineteen  years  of  age.  Not 
much  bleeding  occurred  at  the  time  of  the  operation, 
but  in  the  evening  the  dressings  (Lister)  wrere  filled 
with  blood ;  they  were  removed  for  the  same  cause 
daily  during  the  next  four  days,  and  then  a  drainage- 
tube  inserted.  Ten  days  later  the  patient  lost  six 
ounces  of  blood;  as  the  haemorrhage  continued,  the 
wound  was  enlarged.  The  end  of  the  lower  frag- 
ment was  found  posteriorly,  and  from  it  projected  a 
sharp  spicula  of  bone.  The  ends  of  the  fragments 
were  excised  and  the  popliteal  artery  exposed.  It 
was  then  found  that  there  was  a  small  hole  on  its 
anterior  aspect  of  the  size  of  the  splinter  of  bone. 
The  artery  was  ligated  above  and  below  the  point 
of  puncture.  The  next  day  the  leg  became  gangre- 
nous, and  an  amputation  was  performed  two  inches 
above  the  end  of  the  upper  fragment.  The  patient 
died  the  same  evening.  McGrill2  reports  a  case  in 
which,  during  a  supra-condyloid  operation,  the  pop- 
liteal artery  was  completely  divided  transversely,  the 
vessel  was  exposed,  and  both  ends  ligated  with  anti- 
septic catgut.  The  patient  made  a  good  recovery, 
the  deformity  being  relieved. 

1  "  Lancet,"  March  29,  1884,  p.  564. 

2  "Lancet,"  May  17,  1884,  p.  891. 


116  OSTEOTOMY. 

In  two  cases  the  an&stomotica  magna  has  been  di- 
vided during  a  Maeewen's  operation — once  by  Ger- 
ster  '  and  once  by  Marsh.2  In  both  of  these  cases  the 
point  of  the  incision  in  the  skin  was  determined  by 
Maeewen's  rule,  and  the  limb  was  operated  upon 
with  the  leg  in  an  extended  position. 

There  have  been  other  deaths  reported,  viz. :  from 
diphtheria,  meningitis,  pneumonia,  and  uraemia ;  but 
they  should  not  be  attributed  to  the  operation.  It 
is  claimed  by  Macewen,  and  I  think  justly,  that 
Dunlap's  operation  was  not  a  strictly  supra-con dyloid 
section  according  to  his  method.  It  was  performed 
with  a  chisel,  and  not  an  osteotome,  "and  the  line 
of  the  section  was  zigzag." 3  But  as  the  fatal  issue 
was  not  due  to  anything  about  the  wound,  but  to 
an  error  in  dressing,  even  this  case  should  not  be 
charged  to  the  operation.  Bull's  case  of  carbolic- 
acid  poisoning  is  excluded  on  the  same  ground. 
There  has,  therefore,  been  but  one  death  recorded 
from  the  operation. 

In  thirty  cases  the  section  was  made  from  the 
outside.  In  twenty-seven  of  these  the  bone  was 
divided  with  a  saw ;  in  the  other  cases  an  osteotome 
was  used.  In  eleven  cases  section  was  made  with  a 
saw  in  Maeewen's  line.  In  none  of  these  did  sup- 
puration occur.  There  have  been  ten. cases  recorded 
in  which  suppuration  has  occurred  after  a  supra-con- 
dyloid  operation,  and  in  none  of  these  did  the  pus 
communicate  with  the  bone.  There  have  no  doubt 
been  many  other  cases  in  which  it  has  occurred,  but 
no  record  has  been  made  of  the  fact. 

1  "N.  Y.  Med.  Jour.,"  February  23,  1884,  p.  227. 

s  "Brit.  Med.  Jour.,"  April  5,  1884,  p.  665.         3  Private  note. 


OSTEOTOMY  FOR   GENU   VALGUM.  H7 

In  one  case  (Taylor1)  there  was  some  effusion  into 
the  joint  a  day  or  two  after  the  operation.  Weir  also 
reported  a  case  where  this  took  place  some  weeks  after 
the  operation,  when  the  patient  began  to  use  this  limb. 
In  the  latter  case  it  is  probable  that  the  effusion  was 
due  to  over-exercise.  In  two  cases  considerable  stiff- 
ness persisted  for  some  time  (Wright,2  Rabagliati3). 
In  one  case  the  deformity  returned,  and  Ogston's 
operation  was  performed  with  a  good  result.  In  this 
case  the  section  was  made  from  the  outside  ;  the  pa- 
tient may  possibly  have  been  permitted  to  go  about 
before  the  new  bony  deposit  had  become  well  con- 
solidated, and  the  deformity  thus  reproduced.  In 
one  case  the  joint  was  fractured  into  during  the  sec- 
tion (Rabagliati4).  The  patient  recovered,  but  with 
restricted  motion  in  the  joint.  This  is  the  only  case 
in  which  this  accident  has  ever  been  reported.  It 
may  have  been  due  to  the  rise  of  an  osteotome  of 
too  great  thickness,  and  driving  it  after  it  had  be- 
come tightly  wedged. 

Ogston's  Operation. — Out  of  one  hundred  and  ten 
cases,  only  two  are  reported  to  have  died — one  from 
septic  pneumonia  (Baker),  and  one  from  uraemia 
(Thiersch),  six  weeks  after  the  section.  The  latter 
can  not  be  attributed  to  the  operation. 

Suppuration  is  reported  by  Jones,  Schonborn, 
Sonnenburg,  and  Margary.  In  three  cases  it  was  con- 
siderable. In  one  it  involved  the  joint,  necessitat- 
ing many  incisions  and  drainage.  In  one  case  a  trou- 
blesome synovitis  persisted  for  some  time  (Callen- 

1  "Brit.  Med.  Jour.,"  April  7,  187Y,  p.  429. 

i  Loc.  tit.  a  Loc.  pit. 

4  "Brit.  Med.  Jour.,"  November  24,  1883,  p.  1006. 


118  OSTEOTOMY. 

der).  In  almost  all  cases  there  was  more  or  less 
effusion  for  a  few  days.  Three  patients  recovered 
with  complete  ankylosis,  and  one  of  them  with  the 
limb  flexed  at  a  right  angle,  while  in  four  there  ex- 
isted for  many  months  marked  stiffness  of  the  knee 
joint.  Acute  pain  in  the  knee  joint,  lasting  several 
days,  seemed  to  have  been  not  an  infrequent  occur- 
rence. 

In  one  case  the  saw  broke,  and  was  left  in  the 
bone.     No  complication  followed. 

Reeved s  Linear  Section  with  Chisel  in  Ogston's 
Line. — In  thirty-seven  cases,  of  which  record  can  be 
found,  the  ultimate  result  has  been  good  in  all  ex- 
cept one  (Haward),  where  the  chisel  broke  in  the 
condyle,  and  was  extracted.  Swelling  of  the  knee 
and  thigh  followed,  with  free  suppuration,  and  after 
recovery  the  limb  was  straight  while  the  patient  was 
lying  down,  but,  when  any  weight  was  brought  to 
bear  upon  it,  it  bent  inward.  Besides  the  above 
case,  suppuration  has  been  reported  in  three  others 
(Holmes,  Sterling,  and  Briddon).  Baker1  states  that 
he  has  collected  fifty-seven  cases  of  Reeves's  opera- 
tions. In  one  case  there  was  effusion  into  the  knee 
joint. 

BarweIVs  Linear  Section  of  Femur  and  Tibia. — 
In  twenty  cases,  recovery  is  reported  as  having  taken 
place  in  all.  Suppuration  from  the  femoral  wound 
occurred  in  one  case,  a  slight  synovitis  in  one,  and 
the  external  lateral  ligament  was  ruptured  once2 
during  the  operation.  In  most  of  these  cases  the 
tibial  section  was  made  from  three  weeks  to  three 

1  "  Brit.  Med.  Jour.,"  18*79,  vol.  ii,  p.  3. 

2  Margary,  Caiapenon,  loc.  cit. 


OSTEOTOMY  FOR   GENU   VALGUM.  H9 

months  after  the  femoral ;  in  a  few,  however,  both 
sections  were  performed  on  the  same  day. 

Linear  Osteotomy  of  the  Tibia  (Billroth). — Of 
thirty-one  limbs  on  which  this  operation  was  per- 
formed, in  thirty  firm  union  was  established.  In 
one  case  a  slight  synovitis  is  reported,  lasting  six 
weeks.  In  one  case  there  was  high  temperature  and 
great  pain,  followed  by  gangrene  of  the  foot,  neces- 
sitating an  amputation  at  the  lower  third  of  the  leg 
(Margary). 

Cuneiform  Osteotomy  of  the  Tibia  (Mayer  and 
Schecle). — In  twenty-two  limbs  submitted  to  this 
operation,  recovery  took  place  in  all ;  in  one  case 
osteomyelitis  and  suppuration  followed  the  opera- 
tion. 

Cuneiform  Osteotomy  at  loiver  end  of  Femur 
(Chiene  and  Macewen). — In  fourteen  cases,  there  was 
one  death  from  suppuration  and  erysipelas.  At  the 
time  of  death  the  bones  were  united.  A  good  recov- 
ery is  reported  in  the  remaining  cases. 

In  osteotomies  for  the  relief  of  genu  valgum  there 
have  been  only  three  deaths  that  were  due  to  the  op- 
eration. Suppuration  is  reported  to  have  occurred 
in  nineteen  limbs.  In  five  cases  the  joint  was  stiff 
to  a  greater  or  less  degree,  in  four  firm  ankylosis 
took  place,  and  in  two  amputation  had  to  be  per- 
formed on  account  of  gangrene  of  the  foot.  In  nine 
limbs  the  result  was  only  an  improvement. 

ILLUSTRATIVE   CASES. 

Case  I. — Anna  A.,  four  and  a  half  years  of  age, 
was  admitted  into  St.  Mary's  Hospital  in  February, 
9 


120 


OSTEOTOMY. 


1881.  She  lias  enlarged  epiphyses,  and  gives  a  clear 
history  of  rickets. 

Macewen's  supra  -  condyloid  operation  was  per- 
formed on  both  femora  March  17,  1881.  The  limbs 
were  immediately  put  up  in  a  plaster-of-Paris  band- 
age. A  fenestra  was  cut  over  the  seat  of  the  wounds 
on  the  19th,  at  which  time  they  were  found  to  have 
closed,  the  point  of  incision  being  represented  by  a 
fine  line  only.  On  April  16th  the  splints  were  re- 
moved.    Union  firm. 

Fig.  28  is  from  a  photograph  taken  at  time  of  ad- 
mission; Fig.  29  at  date  of  discharge. 

Case  II. — George  R.,  colored,  aged  six  years,  came 


Fig.  28. 


under  my  care  in  April,  1882.  He  shows  marked 
rachitic  changes  in  all  the  long  bones.  The  femurs 
have  an  anterior  curvature,  both  internal  condyles 
are  much  depressed,  and  there  is  an  acute  bend  out- 
ward just  below  the  epiphysis  of  the  tibia.     There 


OSTEOTOMY  FOR   GENU   VALGUM. 


121 


is  also  an  anterior  curvature  of  the  bones  of  the  legs. 
Figs.  30  and  31  are  from  photographs,  and  are  a  good 
illustration  of  a  marked  case  of  rachitic  curvature. 
Walking  is  very  difficult.  There  is  considerable  re- 
laxation of  the  ligaments. 

On  May  1,  1882,  I  performed  Macewen's  opera- 
tion upon  the  right  femur,  and  a  linear  osteotomy  on 


Fig.  29. 


the  left  tibia  just  below  the  tubercle.  The  femoral 
wound  closed,  but  from  the  tibial  there  was  some 
slight  suppuration.  By  these  operations  considerable 
improvement  was  obtained.  In  October,  1882,  the 
same  operation  was  done  on  the  left  femur,  and  a 
linear  osteotomy  on  the  right  tibia  and  fibula. 
The  limbs  were  apparently  brought  into  good  posi- 
tion. The  bones  were  neither  hard  nor  soft.  There 
was  an  abscess  in  connection  with  the  femoral  wound 
which  burrowed  up  under  the  splint,  and  was  opened 
on  the  lateral  aspect  of  the  thigh  above  the  plaster- 


122 


OSTEOTOMY. 


of-Paris  bandage.    The  operation-wound  had  closed. 
After  evacuating  the  matter,  the  abscess  cavity  con- 


Fig.  30. 


Fig.  31. 


OSTEOTOMY  FOR   GENU   VALGUM. 


123 


tracted  down  and  the  discharge  ceased.  On  remov- 
ing the  splints,  the  deformity  was  found  to  still  per- 
sist, but  in  a  much  less  degree.  During  the  winter 
and  spring  an  attempt  was  made  to  correct  what  re- 
mained of  the  deformity  with  splints,  but,  owing  to 
the  relaxed  condition  of  the  ligaments,  it  was  im- 
possible to  gain  any  improvement.  During  the  past 
summer  he  was  down  at  the  sea-side,  where  he  greatly 
improved  in  every  respect  except  the  curvature  of 
the  bones. 

In  October,  1883,  I  made  a  cuneiform  osteotomy 


Fig.  32. 


of  both  tibiaa  from  the  inside,  just  below  the  level  of 
the  tubercle.  Sufficient  bone  was  removed  to  allow 
the  tibia  to  be  brought  into  a  straight  line  with  the 
femur.  The  wounds  were  treated  in  the  usual  man- 
ner, and  horse-hair  drainage  used.  The  following 
day  it  was  removed.  There  has  not  been  a  particle 
of  suppuration.  In  November,  1883,  the  splints 
were  removed.     Fig.  32  shows  his  present  condition. 


124 


OSTEOTOMY. 


There  is  still  a  marked  anterior  curvature  of  the 
shaft  of  the  tibia. 

This  case  illustrates  one  of  the  worst  deformities 


Fig.  33. 


Fig.  Si. 


OSTEOTOMY  FOR   GENU   VALGUM. 


125 


I  have  ever  attempted  to  treat,  and  is  used  not  so 
much  to  exhibit  a  perfect  correction  as  to  show  what 
may  be  accomplished  in  so  unpromising  a  case. 

Case  III. — Lillie  B.,  four  years  of  age,  has  genu 
valgum  of  rachitic  origin  in  right  limb,  due  to  a 
depression  of  the  plane  of  the  internal  condyle  and 


Fig.  35. 


some  elevation  of  the  inner  head  of  the  tibia.     Fig. 

33  is  from  a  photograph,  and  shows  the  extent  of  the 
deformity. 

On  March  14,  1881,  a  supra-con dyloid  operation 
was  performed.  On  examination  of  the  wound  on  the 
seventh  day,  it  was  found  to  be  represented  by  a  fine 
line.  April  15th  the  plaster-of- Paris  splint  was  re- 
moved, and  correction  was  found  to  be  perfect.     Fig. 

34  shows  the  condition  of  the  limb  at  time  of  dis- 
charge from  the  hospital. 


120 


OSTEOTOMY, 


Case  IV. — W.  S.,  fourteen  years  of  age,  was  ad- 
mitted into  St.  Mary's  Hospital  in  February,  1881. 
He  is  very  small  for  his  age,  has  misshapen  chest  and 


k&sfe? 


Fig.  SG. 


other  rachitic  deformities,  together  with  genu  valgum. 
The  ligaments  of  the  knee  joint  are  relaxed.  . 

Fig.  35  is  from  a  photograph  taken  shortly  after 
admission,  and  shows  the  amount  of  the  deformity. 

On  February  25,  1881,  Macewen's  supra-condy- 
loid  osteotomy  was  performed  upon  both  limbs,  and 
immediately  put  in  plaster -of- Paris  splints.  The 
wounds  were  found  closed  on  the  27th,  and  the 
splints  were  removed  on  the  7th  of  April,  at  which 
time  consolidation  between  the  fragments  was  firm. 
Fig.  36  is  from  a  photograph  taken  after  he  left  the 
hospital. 


CHAPTER  VI. 

GENU   VARUM. 

Genu  Varum  lias  been  described  by  some  writers 
on  deformities  as  the  reverse  of  genu  valgum,  and 
that  the  pathological  changes  found  in  the  former 
are  similar  to  those  met  with  in  the  latter,  except 
that  they  occupy  the  opposite  side  of  the  limb.  This 
is  an  error,  at  least  in  the  vast  majority  of  cases.  The 
deformity  in  genu  varum  seldom  has  that  angular 
appearance  so  characteristic  of  knock  knee.  The 
whole  limb  from  the  trochanter  to  just  above  the 
malleolus  forms  a  long  curve,  the  femur  and  tibia 
apparently  being  equally  involved,  whose  greatest 
convexity  is  at  the  knee  joint.  There  are,  however, 
a  few  cases  that  present  an  angular  appearance 
at  the  knee  joint.  I  have  met  one  case  in  which 
the  deformity  was  due  to  a  lengthening  of  the  ex- 
ternal condyle,  resembling  the  condition  often  found 
in  knock  knee.  Reeves1  reports  a  case  of  hyper- 
trophy of  the  external  condyle.  Genu  varum  of  a 
marked  degree  is  not  as  common  a  deformity  as 
genu  valgum,  nor  are  all  cases  of  apparent  bowing 
outward  of  the  limb  to  be  classed  as  cases  of  this 
deformity.  Many  examples  of  uncomplicated  cur- 
vature of  the  tibia  present  an  appearance  of  genu 

1  "  Trans.  Clin.  Soc,"  London,  1879,  p.  32. 


128 


OSTEOTOMY. 


varum,  but,  on  correcting  the  tibial  curve,  the  whole 
deformity  is  removed,  thus  proving  that  the  femur 
was  not  involved.  Fig.  37  illustrates  this.  In  other 
examples  there  may  be  a  slight  bending  of  the 
femur.  Again,  a  curvature  of  the  thigh  may  not  be 
observed  until  the  tibial  curve  has  been  corrected. 

Genu  varum  may  be  present  in  one  limb  and  genu 
valgum  in  the  other.  This  deformity  may  be  com- 
plicated by  other  curvatures  of  the  bones  of  the  leg. 


Fig.  37. 


The  cause  of  genu  varum  is  rickets,  and  in  the 
majority  of  cases  the  femoral  is  secondary  to  the 
tibial  curve. 

Patients  affected  with  genu  varum  to  any  marked 
degree  walk  in  an  awkward  manner,  but  there  is  not 
as  much  pain  from  this  deformity  as  from  genu 
valgum. 

The  elements  going  to  form  this  deformity  being 
so  variable,  no  strict  rule  can  be  laid  down  as  to  its 


GENU  VARUM.  129 

management.  The  same  remarks  that  were  made 
with  regard  to  the  mechanical  treatment  of  knock 
knee  apply  with  equal  force  to  cases  of  genu  varum. 
When  an  operation  is  called  for,  it  will  often  be 
found  that  a  correction  of  the  most  marked  curve, 
which  is  generally  the  tibial,  will  remove,  or  almost 
remove,  the  deformity,  so  that  no  other  section  is 
called  for.  An  osteotomy  should  be  performed  at 
the  point  of  greatest  curvature  in  each  bone,  and  the 
bone  in  which  the  most  marked  bend  exists  should 
always  be  divided  first.  In  marked  cases,  several 
osteotomies  are  necessary  to  entirely  correct. 

Theoretically,  the  section  should  be  made  of  the 
tibia  from  without  inward ;  but,  on  account  of  the 
difficulty  of  getting  at  the  bone  on  its  outer  aspect, 
and  the  vessels  in  close  proximity  to  it  in  this  situa- 
tion, it  is  not  practical,  and  its  division  is  made  from 
before  backward.  The  fibula  should  always  be 
divided  first.  Section  of  the  femur  is  best  made  from 
the  outside. 


CHAPTEE  VII. 

OSTEOTOMY  FOB  ANKYLOSIS  OF  THE  KNEE  JOINT. 

Osteotomy  for  ankylosis  of  the  knee  joint  was 
first  performed  by  J.  Rhea  Barton,1  who  made  a 
cuneiform  section  of  the  femur  at  its  lower  extremity. 
The  late  Gurdon  Buck,  in  1844,  modified  Barton's 
operation  by  including  the  ends  of  the  femur  and 
tibia  together  with  the  patella  in  the  wedge. 

Since  then  other  operations  have  been  performed. 
They  can  be  best  considered  under — 

1.  Operations  upon  the  femur. 

2.  Operations  upon  the  tibia. 

3.  Operations  upon  the  femur  and  tibia. 

4.  Operations  upon  the  joint  itself. 

1.  Operations  'upon  the  Femur. — Barton's  opera- 
tion, performed  in  1835,  for  bony  ankylosis  of  the 
knee  joint  at  a  right  angle,  consisted  in  removing  a 
V-shaped  piece  of  bone,  base  forward,  from  just 
above  the  condyle  of  the  femur,  in  the  following 
manner:  The  bone  was  reached  by  an  angular- 
shaped  flap,  base  outward,  made  just  above  the  con- 
dyles, and  a  V-shaped  piece  of  bone  then  removed, 
the  apex  not  extending  entirely  through  the  thick- 
ness  of  the  shaft.     The   section   was  made  with  a 

1  "Am.  Jour.  Med.  Sciences,"  1837,  vol.  xxi,  p.  332. 


ANKYLOSIS  OF  TEE  KNEE  JOINT.  131 

saw,  and  the  remaining  portion  of  the  shaft  frac- 
tured by  bending  the  \eg.  The  line  of  incision 
was  closed  by  sutures  and  adhesive  plaster,  and 
the  limb  placed  upon  a  double  inclined  plane. 
After  some  days  the  leg  was  gradually  brought  up 
into  a  straight  line  with  the  femur.  The  object  in 
not  immediately  correcting  the  deformity  was  that 
the  rousfh  ends  of  the  divided  bone  mi«:ht  become 
rounded  off  by  inflammatory  action.  Quite  a  num- 
ber of  patients  have  been  operated  upon  by  Bar- 
ton's method,  but  modified  by  the  immediate  instead 
of  the  gradual  correction  of  the  deformity. 

Kilgarriff,1  in  a  case  of  ankylosis  at  a  right  angle 
following  extensive  injury  to  the  knee,  slightly 
modified  Barton's  operation  by  making  a  complete 
section  of  the  bone.  His  reasons  for  this  mode  of 
operating  were  that  the  skin  over  the  knee  had  been 
entirely  replaced  by  cicatricial  tissue,  and  he  desired 
to  remove  more  bone  than  a  strict  Barton's  opera- 
tion would  accomplish.  Schillbach  is  reported  by 
Heyfelder  (p.  108)  to  have  made  a  complete  resec- 
tion with  a  chain-saw  of  a  wedge-shaped  segment  of 
the  femur.  Pancoast2  operated  upon  the  shaft  by 
perforating  the  bone  in  different  directions  in  the 
line  of  desired  fracture  with  a  gimlet  through  a 
small  wound,  and  then  breaking  the  bone.  An  ab- 
scess formed  at  the  seat  of  operation,  but  eventually 
the  patient  made  a  good  recovery,  the  limb  being 
nearly  in  a  straight  position.  In  the  following  year 
Brainard,  of  Chicago,  operated  upon  the  condyles, 
the  bone  at  this  point  being  perforated  by  an  instru- 

1  "Dub.  Med.  Jour.,"  March,  1880,  p.  189. 

2 "Med.  and  Surg.  Reporter,"  March  5,  1859,  p.  408. 


132  OSTEOTOMY. 

merit  devised  for  this  purpose.  He  was  unable  at 
the  time  to  fracture  the  bone,  but  some  days  later, 
after  innarnniatory  action  had  been  set  up,  the  bone 
easily  gave  way.  Stephen  Smith '  attempted  to  per- 
form Brainard's  operation,  but  was  unable  to  fracture 
the  bone,  even  after  inflammatory  action  had  lasted 
for  some  time. 

Langenbeck,  in  1862,  practiced  subcutaneous 
osteotomy  above  the  condyles  by  means  of  his  per- 
forator and  small  saw,  but  the  operation  can  not  be 
considered  a  strict  subcutaneous  one  as  such  sections 
are  now  peformed. 

Barwell2  performed  a  linear  osteotomy  with  a 
chisel,  two  inches  above  the  lower  end  of  the  femur, 
for  the  correction  of  angular  ankylosis  at  the  knee 
joint,  with  excellent  results.  A  few  months  later 
Macewen,  in  April,  1875,  operated  antiseptically  in 
a  knee  joint  in  a  similar  manner. 

2.  Operations  upon  the  Tibia. — Wahl,  of  St.  Peters- 
burg, in  1877  performed  a  cuneiform  osteotomy  upon 
the  tibia  just  below  the  tubercle  for  the  relief  of 
a  knee  ankylosed  at  a  right  angle.  The  operation 
was  followed  by  suppuration  and  necrosis.  Margary 
repeated  this  operation,  but  with  better  success.  It 
does  not  seem  to  have  been  a  favorite  operation,  and 
has  had  but  few  advocates. 

3.  Operations  upon  the  Femur  and  Tibia. — This 
includes  cuneiform  excision  of  the  ankylosed  joint 
and  linear  osteotomy  of  both  bones.  Buck,3  in  1844, 
modified  Barton's  operation  by  removing  a  wedge- 

1  "Am.  Med.  Times,"  1860,  vol.  i,  p.  310. 

2  "Brit.  Med.  Jour.,"  April  28,  1878,  p.  807. 

3 "Am.  Jour.  Med.  Sciences.,"  October,  1S45,  p.  277. 


ANKYLOSIS   OF  THE  KNEE  JOINT.  133 

shaped  piece,  which  included  the  articular  ends  of 
the  femur  and  tibia,  together  with  the  patella,  and 
immediately  rectifying  the  position  of  the  leg.  The 
apex  of  the  V-shaped  section  did  not  reach  the  pos- 
terior portion  of  the  bones,  a  bridge  of  bone  being 
left,  which  was  fractured.  The  object  in  this  was  to 
obviate  any  danger  of  injury  to  the  popliteal  vessels. 
The  operation  is  really  an  excision  of  an  ankylosed 
joint.  It  has  been  adopted  in  the  vast  majority  of 
cases  of  bony  ankylosis  of  the  knee  joint  at  an  angle, 
and  records  of  its  success  are  scattered  through  the 
medical  journals  since  the  day  of  its  first  performance. 

Eutriken l  deviated  from  Buck's  operation  in  that 
lie  included  the  whole  thickness  of  the  bones  in  the 
section  on  account  of  the  marked  contraction  of  the 
tissues  behind  the  joint,  requiring  the  removal  of 
more  bone  than  was  possible  by  Buck's  section.  The 
same  end,  however,  could  have  been  accomplished 
by  making  the  cuts  as  designed  by  the  first  operator, 
and  then  removing  additional  pieces  until  the  nec- 
essary amount  of  bone  had  been  removed.  Buck's 
operation  is  certainly  a  safer  one  in  that  the  vessels 
are  protected  by  a  bridge  of  bone  from  the  saw. 

In  marked  cases  of  deformity  at  the  knee  joint 
submitted  to  a  linear  osteotomy,  most  operators  have 
advised  and  practiced  two  sections:  one  at  the  lower 
end  of  the'  femur,  by  which  half  of  the  desired  cor- 
rection was  obtained,  and  later  a  division  of  the  tibia 
just  below  the  tubercle,  by  which  the  remainder  of 
the  deformity  was  removed.  The  advantage  of  this 
operation  is  that  the  shortening  of  the  limb  is  not 
increased,  while,  on  the  other  hand,  it  leaves  the 

1  "  The  Clinic,"  March  12,  1876. 


134  OSTEOTOMY. 

joint  prominent  and  misshapen.  Time  will,  how- 
ever, diminish  this  deformity  to  some  extent.  In 
correcting  after  a  linear  osteotomy  there  is  an  enter- 
ing angle  left  on  the  posterior  aspect  of  the  bone,  its 
size  varying  with  the  amount  of  correction  made. 
This  in  time  is  obliterated  by  the  formation  of  new 
bone. 

There  have  been  two  operations  performed  upon 
the  joint  itself,  in  order  to  break  up  the  bony 
bands  between  the  bones.  In  1861  Gross1  per- 
formed a  subcutaneous  operation  by  entering  the 
joint  itself  with  a  perforator  and  after  dividing  or 
breaking  up  all  adhesions,  placed  the  limb  in  the 
desired  position,  the  operation  being  performed 
through  an  incision  one  half  an  inch  long.  He  re- 
ports six  successes  out  of  seven  patients  operated 
upon.  Stromeyer  Little,2  in  18G8,  divided  the  uniting 
bands  between  the  femur  and  tibia,  in  a  case  of  bony 
ankylosis  of  the  knee  joint,  with  a  carpenter's  chisel, 
one  fourth  of  an  inch  wide,  through  a  small  incision, 
and  then  brought  the  leg  into  a  straight  position. 
The  wound  closed  without  suppuration  by  the  sixth 
day.  Dr.  H.  B.  Sands,  of  this  city,  has,  I  believe, 
performed  a  similar  operation.  Of  these  operations 
for  correcting  ankylosis  of  the  knee  joint  at  an 
angle,  that  of  Buck  (cuneiform  osteotomy),  removing 
a  V-shaped  piece  from  above  the  joint,  and  linear 
osteotomy  of  the  femur  and  tibia,  are  mainly  prac- 
ticed. Buck's  operation  does  not  properly  belong  to 
osteotomies,  but  rather  to  excision. 

Linear  osteotomy  for  angular  deformity  at  the 

^'System  of  Surgery,"  1882,  vol.  i,  p.  1096. 
2  "  Medico-Chir.  Trans.,"  vol.  iv,  p.  247. 


ANKYLOSIS   OF  THE  KNEE  JOINT.  135 

knee  joint  is  performed  as  follows  :  The  limb  should 
be  rendered  bloodless,  and  a  small  incision  made  by 
the  side  of  the  rectus  tendon,  at  a  point  a  finger's 
breadth  above  the  upper  portion  of  the  external 
condyle,  of  sufficient  length  to  admit  the  osteotome. 
This  latter  instrument  is  then  passed  down  upon 
the  knife  as  a  guide,  and  the  femur  divided  as  in 
other  osteotomies  until  it  can  be  easily  fractured. 
If  the  deformity  is  great,  it  is  well  to  make  in  addi- 
tion a  section  of  the  tibia  just  below  the  tubercle, 
and  divide  the  amount  of  correction  between  the 
two  bones.  Barwell  makes  the  section  of  the  tibia 
two  weeks  later,  while  Macewen  operates  upon  both 
bones  upon  the  same  day.  The  nearer  to  the  joint 
the  section  is  made,  the  less  will  the  knee  project 
after  the  correction  is  made.  In  time,  however,  the 
deformity  is  diminished  by  rounding  off  and  filling 
up  any  projection  and  depression,  so  that  in  a  year 
after  the  operation  the  appearance  of  the  limb  has 
greatly  improved.  The  shortening  of  the  limb  is 
less  than  after  a  cuneiform  osteotomy.  Macewen 
reports  no  shortening  in  some  of  liis  cases. 

The  only  accident  after  a  linear  osteotomy  that  I 
have  seen  mentioned  is  gangrene  from  compression 
of  the  popliteal  vessels  from  the  acuteness  of  the 
bend  after  straightening  the  limb. 

I  have  never  performed  the  operation  of  simply 
dividing  the  bone.     I  think  that  a  Buck's  operation 
is  the  safer  and  better. 
10 


CHAPTER  VIII. 

OSTEOTOMY  FOB  TIBIAL   CURVES. 

Tibial  curves  may  be  studied  under  three  condi- 
tions: rachitic,  traumatic,  and  pathological.  As  in 
other  deformities  of  the  long  bones,  the  vast  majority 
of  cases  of  bending  of  the  bones  of  the  legs  are  in- 
cluded in  the  first  class.  Rachitic  curvature  of  the 
tibia  and  fibula  belong  to  the  earlier  manifestations 
of  this  disease,  and  usually  begin  before  the  third 
year.  Their  cause  is  mechanical — standing ;  sitting 
with  their  feet  bent  under,  or  cross-legged,  a  very 
common  position  for  a  child  affected  with  rickets 
to  assume;  sometimes  the  way  in  which  they  are 
carried  by  their  nurse  is  a  factor  in  the  production 
of  these  deformities ;  in  fact,  almost  any  position  will 
produce  a  curvature  of  these  bones  in  a  young  child 
affected  with  rickets.  I  have  never  been  able  to  sat- 
isfy myself  that  the  muscles  of  the  limb  were  an 
active  element  in  their  production. 

Curvatures  of  the  tibia  may  be  lateral,  anterior, 
or  antero-lateral.  The  bending  may  be  confined  to 
the  lower  third  of  the  bone,  just  above  the  malleolus, 
where  a  sharp,  almost  angular  curve  may  be  found ; 
it  may  involve  the  whole  bone,  from  just  below  the 
upper  epiphysis  to  the  malleoli,  or  there  may  be  a 


OSTEOTOMY  FOR   TIBIAL    CURVES.  137 

sharp,  short  curvature  at  its  lower  third,  and  then 
a  long  one  above,  or  the  bone  may  have  only  one 
long  anterior  curve.  In  marked  cases  the  tibia  is 
often  flattened  from  before  backward,  or  from  side 
to  side.  In  the  latter  cases  the  spine  is  much  sharper 
and  seems  more  prominent.  In  anterior  curvatures 
the  bone  is  often  elongated  on  its  anterior  border,  and 
overhangs  the  foot  (as  in  Fig.  38).     Lateral  curva- 


Fig.  38. 


ture  of  the  tibia  and  fibula  with  that  of  the  femur, 
form  genu  varum. 

Traumatic  deformities  of  these  bones  have  their 
origin  in  fractures,  which,  for  one  reason  or  another, 
have  been  allowed  to  unite  at  an  angle.  To  this 
class  belong  intra-uterine  fractures.  These  are  almost 
always  angular ;  some  few  cases  of  simple  bending 
are  reported.  Deformities  from  this  cause  are  not  as 
frequently  met  with  as  formerly,  owing  to  improved 
methods  of  treating  these  injuries.  The  greater  por- 
tion occupy  the  middle  third,  and  next  in  frequency 


138  OSTEOTOMY. 

we  find  malposition  of  the  foot,  due  to  fracture  of 
the  lower  portion  of  the  fibula  and  a  chipping  off 
of  the  internal  malleolus  (Pott's  fracture),  the  foot 
being  turned  outward.  Thus,  in  seventy-four  cases, 
fifty-one  occurred  in  the  middle  third  and  twenty- 
three  in  the  lower  portion  of  the  limb.  Operations 
for  the  correction  of  vicious  union  of  the  tibia  and 
fibula  above  the  lower  portion  may  be  resolved  into 
three — a  simple  section,  a  cuneiform  section,  and  an 
excision  of  the  ends  of  the  fragments  after  a  simple 
division.  Of  simple  section  nine  cases  are  reported, 
twenty-six  of  cuneiform  excision,  and  fifteen  of  an 
excision  of  the  ends  of  the  bones  after  a  linear 
section.  Of  the  first  class,  suppuration  is  reported 
in  ten  cases ;  one  patient  died — no  cause  assigned ; 
and  six  were  cured — no  mention  of  the  formation  of 
pus  being  made. 

Of  cuneiform  osteotomies,  in  nine  patients  suppu- 
ration is  reported,  two  died  from  pyaemia;  in  two 
the  limb  was  amputated  subsequently ;  in  one  the 
femoral  artery  was  ligated  to  control  haemorrhage; 
and  thirteen  are  reported  "  cured  " — no  mention  be- 
ing made  of  suppuration. 

Of  re-excision  of  the  ends  of  the  bone  after  a 
simple  division,  in  six  cases  suppuration  is  reported ; 
one  patient  died  from  pyaemia;  in  one  the  limb  was 
amputated  some  time  after  the  operation  for  non- 
union ;  and  in  six  no  accident  is  reported. 

There  have  been  three  operations  performed  for 
the  correction  of  the  malposition  of  the  foot  after  a 
Pott's  fracture — namely,  an  excision  of  the  lower  end 
of  the  tibia,  with  a  division  or  osteoclasis  of  the 
fibula;  an  excision  of  the  internal  malleolus,  with 


OSTEOTOMY  FOR   TIBIAL    CURVES.  139 

fracture  of  the  fibula ;  a  cuneiform  osteotomy,  base 
inward,  on  the  inner  aspect  of  the  tibia,  and  a 
linear  section,  or  simple  fracture  of  the  fibula.  The 
latter  operation  has  lately  been  performed  by  Fen- 
ger,1  of  Chicago.  The  result  of  these  operations  has 
been  to  bring  the  foot  inward  and  so  to  allow  its 
axis  to  correspond  with  that  of  the  knee  and  hip 
joint.  Of  twenty-three  patients  on  whom  these 
operations  have  been  performed,  in  twenty-two  re- 
covery took  place,  with  a  useful  foot,  and  one  died 
on  the  tenth  day  from  purulent  infection.  In  five 
of  these  suppuration  is  reported  to  have  occurred ; 
in  two,  however,  it  was  only  slight.  In  some  of  the 
cases  the  ends  of  the  bones  have  been  wired  together, 
but  recovery  does  not  seem  to  have  been  any  more 
perfect  than  in  those  in  which  this  was  not  done.  It 
is  probable  that  suppuration  occurred  in  more  cases 
than  those  given  above,  as  the  majority  of  cases 
were  operated  upon  before  the  present  methods  of 
operating  and  management  of  wounds  were  adopted. 

In  1861,  Berend,  of  Berlin,3  reported  a  case  of 
marked  deformity  after  a  fracture,  with  ankylosis  of 
the  ankle  joint,  in  which  he  performed  a  cuneiform 
osteotomy  at  the  lower  portion  of  the  tibia  with 
good  result.     Billroth  3  reports  a  similar  case. 

Pathological. — In  this  class  are  included  those 
cases  of  bending  of  the  bone  from  local  diseases — 
as  inflammation  of  bone.  Schede  reports  the  case 
of  a  girl  with  congenital  syphilis  who  had  had  a 
chronic  periostitis  of  the  tibia  for  nine  years,  with 

1  "  Med.  News,"  April  15  and  22,  1882. 

2  Campenon,  loc.  cit.,  p.  186. 

3  "  Wien.  med.  Wochenschrift,"  1881,  p.  414. 


140  OSTEOTOMY. 

elongation  of  the  bone,  eight  to  nine  centimetres,  the 
fibula  not  being  affected.  The  tibia  was  curved, 
with  its  convexity  inward.  Willitts *  mentions  a 
case  in  which  the  tibia  was  bent  at  an  acute  angle 
outward,  following  necrosis  of  the  outer  portion  of 
the  shaft,  near  the  epiphysis.  Similar  cases  may  be 
found  scattered  through  medical  literature.  These 
deformities  are  due  to  an  increased  growth  of  a 
portion  or  the  whole  of  the  bone,  and  consequent 
bending  due  to  the  unequal  growth  of  the  fibula.  It 
is  met  only  among  children  and  adolescents. 

It  is  rather  a  common  belief  among  parents,  and 
to  some  degree  among  physicians,  that  children  af- 
fected with  these  curves  of  the  bones  of  the  leg  will 
outgrow  the  deformity,  and  that  all  local  treatment 
is  uncalled  for.  It  does  not  seem  possible,  while  a 
child  is  running  about,  that  any  real  obliteration  of 
these  curvatures  could  take  place.  They  may,  and 
certainly  do,  in  some  cases,  undergo  a  relative 
change ;  the  bone  increases  in  length  and  thickness, 
while  the  curve  remains  the  same  size  as  at  first,  so 
that  it  is  relatively  smaller  and  less  marked  in  later 
years.  This  is  especially  true  of  short,  sharp  curves 
at  the  lower  end  of  the  tibia.  In  later  years  these 
are  apparently  smaller  and  less  observable.  Long 
anterior  curves  do  not  show  the  same  tendency  to 
become  obliterated.  They  seldom,  if  ever,  diminish, 
and,  when  the  limbs  are  uncovered,  will  always  be 
noticeable. 

Treatment. — The  same  remarks  are  applicable  to 
curvatures  of  the  bones  of  the  legs  due  to  rickets  as 
to  the  deformities  of  other  long  bones  of  similar 

1  "Brit.  Med.  Jour.,"  February  1,  18*79,  p.  151. 


OSTEOTOMY  FOR   TIBIAL    CURVES.  141 

origin.  "While  the  bone  is  soft,  lateral  bending  of  the 
limb  may  be  straightened  by  splints ;  but,  after  they 
have  become  hard,  mechanical  treatment  is  useless. 
Anterior  curvatures  are  not  suitable  for  mechanical 
treatment,  for  the  reason  that  pressure  can  not  be 
applied  over  the  crest  of  the  tibia,  the  sharp  edge  of 
the  bone  cutting  through  the  skin.  It  is  true  that 
in  catalogues  of  instrument-makers,  and  in  some  works 
on  surgery,  braces  are  figured  for  application  over  the 
crest  of  the  tibia  to  correct  anterior  curvatures ;  but 
they  are  entirely  useless. 

When  the  bones  are  only  moderately  sclerosed, 
time  may  be  gained  by  putting  the  patient  under 
ether  and  forcibly  straightening  the  limb,  and  then 
putting  it  up  in  plaster  of  Paris.  Mr.  Howard  Marsh 
speaks  well  of  this  plan.  I  have  adopted  it  in  some 
cases,  and  think  it  an  advantage. 

After  the  bones  have  become  bard,  osteotomy  or 
osteoclasis  must  be  performed.  The  latter  method 
will  be  treated  of  in  another  chapter.  Osteotomy 
for  bow-legs  may  be  either  linear  or  cuneiform.  All 
lateral  and  anterior  curvatures  of  slight  degree  may 
be  corrected  by  a  linear  osteotomy ;  anterior  curves 
of  marked  degree  by  a  cuneiform  section.  Osteotomy 
for  these  deformities  should  be  made  at  the  point  of 
greatest  curvature.  In  all  cases  the  fibula  should  be 
divided  first,  using  a  small  osteotome,  because  the 
bone  is  difficult  to  steady  after  the  tibia  has  been 
fractured,  and  in  cuneiform  sections  the  less  the  parts 
about  the  tibia  are  disturbed  the  better.  It  will  be 
found  easier  to  make  the  section  of  the  fibula  upward 
and  inward.  In  performing  the  tibial  section,  the 
incision  should  be  made  down  upon  the  crest  at  the 


142  OSTEOTOMY. 

point  of  greatest  curvature  parallel  to  the  long 
axis  of  the  bone,  the  instrument  introduced  and 
rotated  so  as  to  be  at  right  angles  with  its  line  of 
entrance.  It  is  best  to  begin  to  divide  from  the  crest 
inward.  Care  should  be  taken  that  the  edge  of  the 
osteotome  does  not  extend  beyond  the  outer  border 
of  the  crest,  as  the  anterior  tibial  artery  may  be  nearer 
to  the  bone  than  normal,  and  is  liable  to  be  divided. 
I  had  this  accident  happen  to  me  in  my  first  case. 
After  the  bone  has  been  divided  through  about  two 
thirds  of  its  thickness,  the  section  can  be  completed 
by  fracture.  The  wounds  are  to  be  treated  in  the 
manner  pointed  out  on  page  22.  I  think  it  well 
to  make  a  counter-opening  on  the  inner  side  of  the 
leg  and  pass  horse-hair  through  for  the  purpose  of 
preventing  any  accumulation  of  blood  separating  the 
edges  of  the  wound.  The  tibia  being  superficial, 
there  is  not  as  much  room  for  the  effused  blood 
as  in  bones  better  covered  with  muscles,  and  I  have 
always  found  that  it  is  liable  to  force  the  line  of  in- 
cision open.  In  simple  lateral  curves  the  thinnest 
osteotome  should  be  used,  as  the  cut  in  the  bone 
should  be  as  narrow  as  possible. 

Cuneiform,  Osteotomy. — Anterior  curvatures,  if 
marked,  are  best  corrected  by  the  removal  of  a  wedge- 
shaped  piece  of  bone.  The  more  angular  the  deformi- 
ty, the  less  will  linear  section  correct.  A  counter- 
opening  should  always  be  made  on  the  inner  aspect 
of  the  leg,  opposite  a  point  corresponding  to  the  apex 
of  the  wedge,  and  carbolized  horse-hair  be  passed 
through  the  cut  and  out  of  the  operation  wound. 
An  easy  way  to  accomplish  this  is  to  pass  a  pair  of 
dressing  forceps  (closed)  down,  through,  and  below  the 


OSTEOTOMY  FOR   TIBIAL    CURVES.  U3 

divided  bone,  and,  by  a  twisting  motion,  force  the  end 
beneath  the  skin  at  the  point  where  it  is  intended 
to  make  the  counter-opening.  The  blades  are  sepa- 
rated and  the  skin  divided  between  them.  The 
horse-hair  is  then  caught  in,  and  the  forceps  drawn 
up  through  the  original  incision.  The  edges  of  the 
cut  on  the  anterior  aspect  of  the  leg  are  to  be  united 
with  antiseptic  gut,  and  over  this  a  small  compress, 
the  wound  having  been  first  washed  out  with  some 
antiseptic.  I  have  used  iodoform,  dusted  over  the 
wound,  but  any  similar  method  of  wound-dressing 
may  be  adopted.  The  whole  limb  and  lower  portion 
of  the  thigh  is  then  incased  in  a  plaster-of-Paris  splint. 
Before  this  becomes  hard  the  limb  is  put  into  the 
desired  position.  It  is  well  to  over-correct  a  little,  as 
after  a  time  the  plaster  splint  becomes  loose  and 
allows  the  position  of  the  limb  to  be  altered.  In  this 
class  of  cases  a  tenotomy  of  the  tendo  Achillis  is  often 
necessary.  The  horse-hair  should  be  removed  upon 
the  second  day  through  a  fenestra  cut  over  the  situa- 
tion of  the  wound.  Its  removal  causes  no  pain. 
The  method  of  performing  a  cuneiform  osteotomy 
has  been  given  with  much  detail,  because  I  am  satis- 
fied, from  personal  experience,  that  its  success — that 
is,  primary  union  of  the  wound — depends  much  more 
upon  the  manner  of  dressing  than  upon  the  way  in 
which  the  section  of  the  bone  is  performed.  In  the 
first  five  cases,  eight  limbs,  in  which  I  removed  a 
wedge-shaped  piece  for  anterior  curvature  of  the 
tibia,  suppuration,  more  or  less  extensive,  occurred  in 
all  the  limbs.  On  examination  of  the  wound  on  the 
second  day,  blood  was  found  to  have  been  effused 
and  to  have  burrowed  up  under  the  skin  to  a  con- 


144  OSTEOTOMY. 

siderable  distance.  The  edges  of  the  wound  were 
separated  by  the  blood,  and,  notwithstanding  the  use 
of  strict  antiseptic  precautions  in  some  cases,  suppu- 
ration invariably  followed,  and  in  one  or  two  cases 
counter-openings  had  to  be  made.  Drainage  from 
the  wound  itself  did  not  seem  to  obviate  the  diffi- 
culty. Since  I  have  adopted  the  plan  mentioned 
above  the  course  of  the  wound  has  been  similar  to 
those  after  a  simple  osteotomy.  I  have  never  seen  a 
drop  of  pus.  In  one  case  I  removed  a  wedge-shaped 
piece  of  bone  from  the  inner  side  of  the  tibia  just 
below  the  epiphysis  in  order  to  correct  an  angular 
deformity  at  that  point;  the  wound  closed  by  pri- 
mary union.  The  pinching  of  a  piece  of  muscular 
and  cellular  tissue  between  the  fragments  may  cause 
suppuration. 

The  haemorrhage  following  a  cuneiform  osteotomy 
is  much  greater  than  after  a  simple  section  of  the 
bone.  Other  things  being  equal,  I  think  that  sup- 
puration is  more  liable  to  follow  an  osteotomy,  be  it 
either  linear  or  cuneiform,  of  a  bone  that  is  subcu- 
taneous, than  of  one  that  is  well  covered  with  mus- 
cles, and  I  attribute  this  to  the  fact  that  in  the  former 
case  any  great  accumulation  of  blood  is  sure  to  cause 
tension  on  the  wound  and  prevent  primary  union. 
Therefore,  the  more  subcutaneous  the  bone,  the 
greater  is  the  necessity  for  a  counter-opening  and 
good  drainage. 

Complications. — There  have  been  two  deaths  re- 
ported after  an  osteotomy  of  the  tibia  and  fibula,  one 
by  Muralt 1  in  a  young  girl  who  died,  some  days  after 
the   date   of  the    operation,   from    diarrhoea      The 

'Boeckel's  Tables. 


OSTEOTOMY  FOR   TIBIAL   CURVES.  145 

autopsy  revealed  nothing  to  account  for  the  fatal 
result.  Gould x  reports  a  fatal  case  in  a  healthy  boy, 
eight  years  of  age,  death  being  due  to  carbolic-acid 
poisoning  thirty-six  and  a  half  hours  after  the  opera- 
tion. In  neither  of  these  cases  can  the  fatal  result  be 
attributed  to  the  operation  itself. 

In  two  hundred  and  fifteen  cases  of  osteotomy 
tabulated  by  Bceckel  and  Campenon,  an  excessive 
haemorrhage  occurred  in  four,  in  forty-one  suppura- 
tion took  place,  and  in  fifteen  a  limited  necrosis  of  a 
portion  of  the  cut  surface  is  reported.  Volkmann 2 
mentions  a  case  in  which  he  amputated  a  limb  on  ac- 
count of  an  enchondroma,  having  its  origin  at  the 
point  of  section.  I  have  lost  two  patients  from 
inter-current  disease  after  firm  union  had  taken  place, 
the  fatal  issue  being  in  no  way  connected  with  the  op- 
eration :  one  from  diphtheria,  and  one  from  meningitis. 

In  regard  to  the  liability  of  the  deformity  to 
return  after  an  osteotomy,  in  one  case  only  have  I 
seen  it,  and  that  was  in  a  boy  five  years  of  age,  on 
whom  a  linear  osteotomy  was  performed  on  both 
limbs  for  lateral  curvature  of  the  tibia.  He  was  an 
inmate  of  an  asylum.  The  bones  were  quite  hard. 
He  was  discharged  with  limb  straight  and  union 
firm.  Five  months  later  he  was  returned  to  the 
hospital  with  an  angular  anterior  deformity  at  point 
of  section,  with  the  statement  that  it  had  only  re- 
cently appeared.  The  boy  at  the  time  of  re-admis- 
sion was  in  poor  condition.  It  would  seem  probable 
that  the  angular  deformity  was  due  to  softening  of 
the  callus,  owing  to  improper  food,  and  not  to  bend- 

1  "  Brit.  Med.  Jour.,"  May  28,  1881,  p.  850. 

2  "  Berl.  klin.  Wocheu.,"  1877,  No.  40,  p.  591. 


146  OSTEOTOMY. 

ing  from  a  soft  condition  of  the  bones.  Billroth  re- 
ports one  case,  of  a  child  four  years  of  age,  in  whom 
the  deformity  (lateral  curvature  of  the  tibia)  re- 
turned after  some  months. 

ILLUSTEATIVE    CASES. 

Case  I. — M.  P.,  four  years  of  age,  was  admitted 
into  St.  Mary's  Hospital,  January,  1879,  with  a 
marked  antero-lateral  curvature  of  both  limbs,  of  ra- 
chitic origin,  most  marked  at  their  lower  third. 

In  February  a  linear  osteotomy  was  performed 
upon  both  tibiae,  a  section  of  the  fibulae  having  been 
first  done.  A  counter-opening  was  made  on  the 
inner  aspect  of  the  limb,  and  carbolized  horse-hair 
passed  through.  The  limbs  were  put  upon  a  tem- 
porary splint,  and,  after  the  wound  had  closed,  a 
plaster-of-Paris  dressing  was  applied.  This  was  kept 
on  until  consolidation  had  taken  place,  when  she  was 
allowed  to  get  up  and  use  her  limb. 

Figs.  39  and  40  are  from  photographs  taken  be- 
fore and  after  section. 

Case  IT. — G.  H.,  four  years  of  age,  was  admitted 
into  St.  Mary's  Hospital,  in  1882,  with  a  marked 
curvature  of  the  bones  of  both  legs  at  their  lower 
third.  The  bones  have  a  lateral,  with  a  marked 
anterior  bend,  so  that  the  crest  of  the  tibia  over- 
hangs the  ankle  joint.  In  February  osteoclasis  was 
performed  upon  both  limbs,  but  only  the  lateral 
curve  could  be  corrected.  The  limbs  were  imme- 
diately put  up  in  plaster  of  Paris  in  a  straight  posi- 
tion as  regards  the  lateral  bend.  In  May  a  cuneiform 
osteotomy  was  performed  upon  both  tibiae,  and  a 
linear  on  the  fibulae,  counter-openings   were   made, 


OSTEOTOMY  FOR   TIBIAL    CURVES. 


147 


carbolized  horse-Lair  passed,  and  the  lips  of  the  tibial 
wounds  were  united  with  carbolized  catgut.  On  the 
following  day  the  horse-hairs  were   removed.     The 


Fig.  39. 


Fig.  40. 


14S 


OSTEOTOMY. 


wounds  healed  by  primary  union.     The  temperature 
was  never  above   99°.     In   four  weeks  the  splints 


Fig.  41. 


Fig.  42. 


were  removed,  and  the  union  was  found  to  be  firm. 
Figs.  41  and  42  show  the  deformity,  and  correction 
obtained. 


CHAPTER    IX. 


OSTEOCLASIS. 


The  correction  of  deformities  of  the  long  bone 
by  fracture  is  an  old  operation,  and  its  history  dates 
back  to  the  time  of  Hippocrates. 

Osteoclasis  may  be  either  manual  or  instrumental. 
Cases  appropriate  to  the  former  procedure  are  de- 
formities after  fracture  and  bending  of  the  long  bone, 
in  the  one  before  union  is  firmly  established,  and  in 
the  other  while  the  bones  are  in  a  pliable  condition. 
In  this  class  should  be  included  cases  of  fibrous,  and 
some  of  bony  ankylosis  of  joints — and  "redresse- 
merit  brusque."  To  instrumental  osteoclasis  is  ap- 
plicable all  cases  of  deformity  after  fracture  and 
curvature  of  the  long  bones,  where  perfect  consolida- 
tion in  the  one  and  sclerosis  in  the  other  has  taken 
place. 

The  cases  that  can  be  corrected  by  manual  os- 
teoclasis are  comparatively  few,  and  even  in  those  in 
which  it  is  possible  to  correct  without  the  use  of  an 
apparatus  for  the  application  of  power,  the  latter  is 
better,  on  account  of  the  precision  with  which  the 
point  of  rupture  can  be  determined.  Fracture,  or 
bending  of  the  bones  of  the  legs,  even  in  quite  young 
children,  is  more  difficult  than  is  supposed. 


150  OSTEOTOMY. 

To  the  operation  by  means  of  an  osteoclast 
belong  the  vast  majority  of  cas.es  of  deformities. 
Osteoclasis  without  an  instrument  requires  but  a 
brief  notice.  The  cases  to  which  it  is  applicable  are 
so  apparent  that  their  recapitulation  would  be  use- 
less except  for  the  correction  of  certain  deformities 
at  the  knee  joint.  I  refer  to  genu  valgum  and  genu 
varum.  Although  redressement  brusque  does  not 
belong  to  the  same  category  as  forcible  correction 
of  fracture,  yet  its  consideration  in  connection  with 
osteoclasis  seems  approj3riate.  The  method  was  first 
advocated  for  rachitic  curvature  by  Guerin  *  in  1 848  ; 
later,  M.  Delore,  of  Lyons,  applied  this  procedure  to 
genu  valgum  and  genu  varum.  It  has  been  a  favorite 
operation  among  the  surgeons  of  the  French  school, 
while  osteotomy  has  had  its  chief  advocates  in  Eng- 
land and  Germany. 

The  object  of  Delore  in  redressement  brusque  was 
to  cause  a  partial  diastasis  between  the  diaphysis  and 
epiphysis  at  the  lower  portion  of  the  femur,  and  then 
to  slide  the  epiphysis  together  with  the  tibia  inward, 
and  thus  correct  the  deformity.  Delore's  method  of 
operating  is  as  follows:  The  patient,  being  fully 
under  the  influence  of  an  anaesthetic,  is  placed  on  the 
side  on  which  the  limb  to  be  operated  uj)on  is  situ- 
ated, with  the  external  malleolus  and  the  upper  por- 
tion of  the  thigh  resting  firmly  on  the  table.  Then, 
by  sudden  and  repeated  applications  of  force  by 
means  of  the  hand  placed  on  the  apex  formed  by  the 
deformity,  the  knee  is  forced  outward  until  the  leg 
assumes  its  normal  relation  to  the  thigh.  The  opera- 
tion is  performed  slowly  and  progressively,  the  time 

1  "  Gaz.  Med.  de  Paris,"  1848,  p.  743. 


OSTEOCLASIS.  151 

required   to    obtain    restitution  varying    from   five 
minutes  to  half  an  hour.     In  young  children  only  a 
very  moderate  pressure  is  required,  while  in  persons 
of  eighteen  or  twenty  years  great  force  is  necessary. 
M.  Taillaux  operates  by  placing  the  patient  upon  the 
opposite  side,  resting  the  knee  upon  a  cushion,  and, 
using  the  leg  as  a  lever,  forces  the  lower  limb  into  the 
desired  position.     The  deformity  gives  way  with  a 
series  of  cracks.     The  lesions  produced  by  this  op- 
eration differ  somewhat  in  different  cases.     Yet  they 
are  all  of  a  serious  nature,  and  are  accompanied  at 
least  by  effusion  into  the  joint,  and  often  by  inflam- 
mation.    In  a  patient  of  Delore's  who  died  of  measles 
twenty  days  after  a  redressement  brusque  for  genu 
valgum,  it  was  found  that  the  lower  epiphysis  of 
the  femur  had   been  partially  detached;  there  was 
considerable  ecchymosis  under  the  periosteum  on  the 
anterior  aspect  of  the  femur;   the  external  portion 
of  the  epiphysis  of  the  tibia  had  been  loosened,  and 
the  end  of  the  fibula  torn  off  and  dragged  upward  by 
the  external  lateral  ligament.     Frequently  the  inter- 
nal condyle  of  the  femur  or  inner  head  of  the  tibia 
is  flattened  or  crushed  in  by  the  amount  of  force 
employed,  while  the  periosteum  is  torn  and  detached. 
In  older  subjects,  fracture  of  the  shaft  has  been  pro- 
duced, or  rupture  of  the  external  lateral  ligament. 
Inflammation  of  the  knee,  more  or  less  intense,  has 
followed  the  operation.     Notwithstanding  the  appa- 
rently severe  nature  of  the  immediate  effects  of  the 
operation,  in  two  hundred  and  fifty  limbs  operated 
upon  by  Delore  he  reports  no  accident ;  and  states 
that  in  about  one  year  all  traces  of  the  operation 
have  disappeared.     But  even  then  the  patient  has  to 
11 


152  OSTEOTOMY. 

be  kept  under  observation  many  months,  and  a  re- 
turn of  the  deformity  is  by  no  means  exceptional. 
Serious  inflammation  of  the  joint  and  suppurative 
periostitis  of  the  shaft  of  the  femur  have  been  re- 
ported. Delore  has  operated  chiefly  upon  children. 
It  is  reported  that  the  injury  to  the  ends  of  the 
bones  entering  into  the  formation  of  the  knee  joint 
has  not  been  followed  by  arrest  of  development  in 
the  limb.  It  would  appear  that  the  nearer  the  pa- 
tient approached  adult  life,  the  more  serious  and  dif- 
ficult the  operation  is. 

Hedressement  brusque  for  genu  valgum  has  had 
but  few,  if  any,  advocates  in  this  country.  That  it 
has  not  been  more  frequently  followed  by  serious 
joint  disease  with  disorganization  of  the  articulation 
is  a  matter  of  surprise.  Perhaps  the  explanation  is 
that  the  operation  has  only  been  performed  in 
selected  cases,  on  patients  who  were  in  good  health 
and  with  no  predisposition  to  tubercular  affections. 
The  fact  that  the  exact  nature  of  the  lesions  produced 
in  any  single  case  are  so  uncertain,  and  the  time 
necessary  to  regain  use  of  the  joint  so  long,  has  de- 
terred most  surgeons  from  adopting  this  operation ; 
and  now  that  a  much  better  and  more  precise  method 
of  correcting  genu  valgum  and  genu  varum  has  been 
devised  in  osteotomy,  it  is  probable  that  redressement 
brusque  is  an  operation  of  the  past. 

Rushton  Parker1  has  reported  some  cases  of  cur- 
vature of  the  femur  and  genu  valgum  treated  by 
osteoclasis  of  that  bone.  His  method  is  as  follows : 
The  knee  joint  was  fixed  in  an  extended  position  by 
means   of  well-padded  iron   splints,  enveloping  the 

1  "Med.  Times  and  Gaz.,"  December  29,  1S83. 


OSTEOCLASIS.  153 

upper  half  of  the  leg  and  the  lower  portion  of  the 
thigh,  so  that  the  part  of  the  limb  below  the  curve 
or  desired  point  of  fracture  should  be  perfectly  im- 
movable and  serve  as  a  lever.  The  thigh  was  then 
laid  on  its  outer  side,  the  upper  part  being  held 
firmly  down  on  the  table,  the  point  of  desired  frac- 
ture just  on  the  edge,  and  the  rest  of  the  limb  pro- 
jecting beyond.  Then,  by  using  the  latter  portion  of 
the  limb  as  a  lever,  fracture  was  readily  produced  at 
the  desired  point.  He  mentions  a  troublesome  syno- 
vitis of  the  knee  joint  in  one  of  his  cases  as  a  result 
of  the  operation. 

Rupture  of  ankylosed  joints  is  a  serious  opera- 
tion. Its  dangers,  however,  are  different  for  different 
articulations,  and  vary  with  the  nature  of  the  uniting 
medium.  In  joints  presenting  extensive  bony  sur- 
faces, and  in  which  bony  union  has  taken  place,  forci- 
ble rupture  is  a  grave  operation.  It  is  often  impos- 
sible to  cause  a  separation  between  the  bones,  and 
fracture  may  take  place  at  a  point  on  either  side  of 
the  joint  and  produce  a  deformity  in  no  way  an  im- 
provement on  the  one  it  was  sought  to  relieve.  It  is 
not  a  safe  operation  for  bony,  and  is  a  very  question- 
able one  in  fibrous,  ankylosis  of  the  hip  joint.  In 
the  former  case  the  enormous  power,  when  the  pelvis 
is  fixed,  that  can  be  brought;  to  bear  upon  the  upper 
end  of  the  femur  will  certainly  produce  a  fracture 
if  the  attempt  is  persisted  in,  but  at  what  point 
depends  upon  where  the  bone  is  the  weakest.  In 
fibrous  ankylosis  after  suppurative  coxalgia,  as  said 
before,  it  is  too  hazardous  an  operation.  In  the  knee 
joint  excellent  results  have  followed  forcible  rupture, 
and,  if  the  band  be  fibrous,  some  useful  motion  is 


154  OSTEOTOMY. 

often  obtained.  It  is  not  entirely  devoid  of  danger 
to  the  popliteal  nerve  and  vessels  behind  the  joint, 
injury  to  which  has  been  recorded.  When  there  is 
much  cicatrical  tissue  behind  the  articulation,  the 
danger  that  the  important  structures  in  that  situa- 
tion maybe  torn  is  not  slight  if  persistent  force  is 
employed.  It  is  questionable  whether  an  osteotomy 
would  not  be  a  better  and  safer  operation  in  this 
class  of  cases,  be  it  linear  or  cuneiform.  In  this  case, 
however,  a  movable  joint  is  not  a  possibility. 

It  should  be  stated,  however,  that  in  ankylosis  of 
the  hip  joint  after  disease,  excellent  results  from  forci- 
ble fracture  have  been  recorded  by  M.  Broca, '  Labo- 
rie, 2  Tillaux, 3  and  by  other  surgeons  in  England  and 
in  this  country.  Yet  its  dangers,  especially  after 
coxalgia,  are  by  no  means  slight.  Disastrous  results 
have  been  too  common,  and  its  results  compare  very 
unfavorably  with  those  of  osteotomy. 

Osteoclasis  by  means  of  an  apparatus  by  which 
considerable  power  can  be  applied  has  been  ad- 
vocated by  all  writers  upon  surgery,  and  many 
instruments  have  been  devised  for  this  purpose. 
The  earlier  operations  were  restricted  to  the  correc- 
tion of  fractures  of  the  long  bone  united  at  an  angle, 
but  later  surgeons  have  extended  the  operation  to 
deformities  of  the  limbs  due  to  other  causes.  Busch, 
Louvier,  Maisonneuve,  and  others,  have  invented  in- 
struments for  the  purpose.  In  1846,  Bizzoli  devised 
an  osteoclast,  which,  with  some  modification,  is  still 
used.     Its  introduction  into  this  country  is  due  to 

1 "  Bull,  de  la  soc.  de  chir.,"  Paris,  vol.  i,  1860,  p.  243. 

^Ibid.,  p.  235. 

3 Ibid.,   18*75,  p.  353. 


OSTEOCLASIS. 


155 


Dr.  A.  T.  Cabot,  of  Boston.1  It  consists  (Fig.  43)  of 
a  heavy  bar,  fifteen  inches  long,  one  inch  wide,  and 
three  eighths  of  an  inch  thick,  being  much  thicker  in 
the  center,  which  is  pierced  for  the  female  portion  of 
a  screw.  Into  this  is  fitted  a  round  steel  bar,  one  half 
an  inch  in  diameter,  on  which  is  cut  a  thread  corre- 
sponding to  the  nut  on  the  long  bar,  and  furnished 
at  its  upper  portion  with  a  handle ;  and  at  its  lower 


Fig.  43. 


extremity  is  a  strong,  well -padded  steel  plate  or 
crutch,  forming  a  segment  of  a  circle.  The  portion 
of  steel  forming  the  male  part  of  the  screw  turns  in 
a  socket  on  the  upper  side  of  this  crutch.  Two  steel 
rings,  five  inches  in  diameter,  one  inch  wide,  and  one 
fourth  of  an  inch  thick,  having  at  their  upper  por- 
tion a  slot  into  which  the  large  bar  slides,  and  to 
which  they  are  fixed  in  any  desired  position  by  bind- 

1<l  Boston  Med.  and  Surg.  Jour.,"  August  14,  18*79,  p.  217. 


156  OSTEOTOMY. 

ing  screws.  The  lower  segment  of  these  rings  are 
well  padded  with  flannel  and  covered  with  chamois. 

In  order  to  increase  the  rapidity  with  which  the 
force  can  be  applied,  I  have  had  three  threads  cut 
upon  the  upright  bar,  which  forms  the  screw. 

Dr.  C.  F.  Taylor,  of  this  city,  has  devised  an  os- 
teoclast— which  is  described  in  the  "Medical  Rec- 
ord" for  April  21,  1877,  p.  241 — for  fracturing  the 
femur  in  a  case  of  bony  ankylosis  with  marked  ab- 
duction and  flexion  of  the  thigh  occurring  after  hip 
joint  disease.  As  the  instrument  is  at  the  present 
time  being  remodeled,  a  description  is  omitted. 
The  instrument  is  an  excellent  one  for  certain 
purposes,  and  should  be  better  known. 

Osteoclasis  has  been  employed  for — 

1.  The  correction  of  deformities  after  fracture. 

2.  For  straightening  ankylosed  joints. 

3.  For  the  correction  of  rachitic  deformities. 
Rizzoli  produced  an  oblique  fracture  of  the  sound 

femur  in  order  to  compensate  for  shortening  of  the 
other  limb.  I  am  not  aware  that  any  other  surgeons 
have  followed  this  plan  of  treatment. 

Osteoclasis  for  deformity  of  the  long  bone  after 
fracture  has  been  performed  by  many  surgeons,  and 
instruments  of  various  designs  have  been  devised  for 
this  purpose.  It  is  an  operation  that  is  attended 
with  but  little  danger,  and  has  yielded  excellent 
results.  Thus,  in  Gurlt's  statistics1  the  femur  was 
fractured  fifty-three  times,  the  leg  twenty-four,  with- 
out an  accident,  and  with  a  good  result  as  to  its 
function  and  use.  The  records  of  hospitals  will 
furnish  many  examples  of  this  method  of  correcting 

luArch.  gen.  de  med.,"  September,  1875,  p.  33S. 


OSTEOCLASIS.  157 

deformities.  The  results  and  technique  are  so  well 
known  to  practical  surgeons  that  an  extended  notice 
is  not  called  for.  Osteoclasis  for  deformity  after  hip 
joint  disease  by  means  of  an  instrument  has  been 
performed.  Most  of  the  apparatuses  used  for  this 
purpose  have  been  devised  for  fracture  near  the  joint 
at  an  uncertain  point.  Taylor's  osteoclast  was  de- 
vised to  produce  a  fracture  at  a  point  entirely  under 
the  control  of  the  surgeon.  From  the  anatomical 
position  of  this  articulation  it  is  impossible  to  select 
a  point  above  the  junction  of  the  middle  with  the 
upper  third,  and  herein  is  the  defect  of  the  osteoclast 
of  Dr.  Taylor.  The  fracture  is  at  a  point  so  far  from 
the  joint  that  the  resulting  deformity  is  considerable, 
and  increases  the  amount  of  shortening. 

Fig.  44  is  from  a  case  reported  in  the  "  Medical 
Record,"  April  21,  1877,  p.  242,  and  shows  the 
amount  of  deformity  after  the  use  of  this  osteo- 
clast. 

Osteoclasis  for  the  Correction  of  Curvature  of  the 
Leg  of  Rachitic  Origin. — For  certain  curvatures  of  the 
bones  of  the  legs  osteoclasis  is  to  be  preferred  to  any 
other  operation,  in  that  it  does  away  with  all  cutting 
and  takes  but  little  time  for  its  performance.  For 
the  past  three  years  I  have  abandoned  osteotomy  for 
long  lateral  and  antero-lateral  bending  of  the  bones 
of  the  les;.  I  do  not  think  that  anterior  curvature  or 
acute  bends  near  the  epiphysis  are  well  adapted  to 
this  means  of  treatment,  for  reasons  that  will  be 
given  farther  on.  I  use  Rizzoli's  osteoclast,  as  de- 
scribed on  page  155. 

The  method  of  using  it  is  as  follows :  The  patient 
being  placed  under  ether  and  the  desired  point  of 


158 


OSTEOTOMY. 


fracture  having  been  determined,  the  limb  is  passed 
through  both  rings,  which  are  adjusted  on  the  straight 
bar  so  that  one  shall  be  just  above  the  lower  and 
the  other  just  below  the  upper  epiphysis  of  the 
tibia.     The  semicircular  pad  should  be  directly  over 


Fig.  4A. 


the  point  of  desired  fracture  on  the  outer  aspect  of 
the  limb.  It  makes  no  difference  whether  the  steel 
plate  at  the  end  of  the  screw  is  equidistant  from  the 
two  rings,  the  point  of  fracture  takes  place  imme- 
diately under  it,  no  matter  where  it  is  placed,  pro- 


OSTEOCLASIS.  159 

vided  it  is  far  enough  from  one  of  the  rings  to  allow 
sufficient  space.  I  do  not  think  that  I  have  ever  had 
less  space  than  two  inches.  I  think  it  safe  to  place 
several  layers  of  flannel  over  the  points  of  pressure 
and  counter-pressure.  After  the  instrument  is  ad- 
justed it  is  made  tight  with  a  few  turns  of  the  screw, 
and  then  the  pressure-pad  is  driven  down  rapidly  by 
turning  the  screw  until  the  bone  gives  way.  It  has 
been  found  that  with  the  instrument  the  fracture 
always  takes  place  directly  under  the  pad,  and  is 
transverse.  I  have  never  seen  or  heard  of  any  in- 
jury to  the  skin,  nor  have  I  seen  any  ecchymosis 
from  the  pressure  of  the  instrument. 

In  some  experiments  with  Rizzoli's  osteoclast,  on 
the  adult  cadaver,  by  Dr.  E.  H.  Bradford,  of  Boston,1 
he  states :  "  The  fracture  was  always  sharply  trans- 
verse, as  if  cut  three  quarters  of  the  way  through  and 
waving  the  rest  without  any  splintering." 

The  reason  I  do  not  think  that  anterior  curva- 
tures are  suited  for  osteoclasis  is  that,  if  force  is  ap- 
plied in  a  direction  from  before  backward,  pressure 
will  have  to  be  made  directly  over  the  crest  of  the 
tibia;  and  in  many  of  these  cases  it  is  much  sharper 
than  in  the  normal  limb,  and  is  not  as  well  covered. 
If  the  fracture  is  made  by  applying  lateral  force,  much 
manipulation  is  necessary  to  bring  the  lower  frag- 
ment forward.  It  has  never  worked  satisfactorily  in 
my  hands.  Angular  deformities  near  the  epiphysis 
I  have  never  tried  to  correct,  as  it  would  be  necessary 
to  place  one  of  the  rings  over  the  epiphysis,  and 
separation  of  that  portion  of  the  bone  might  occur. 
In  this  class  of  cases   I   have  always  performed  a 

1  Private  note. 


160  OSTEOTOMY. 

linear  osteotomy.  I  have  never  had  an  accident  of 
any  kind  happen  after  an  osteoclasis  of  the  bones 
of  the  leg. 

I  think  that,  with  the  above  exceptions,  all  cases 
of  tibial  curves  should  be  corrected  by  osteoclasis. 

Accidents. — A  case  of  non-union  is  reported  by 
Dr.  Fifield.1  It  occurred  in  a  girl,  five  years  of  age, 
who  presented  a  congenital  distortion  of  the  arms 
and  legs.  In  August,  1880,  osteoclasis  was  performed 
on  the  left  tibia  and  fibula.  In  October  of  the  same 
year  a  similar  operation  was  done  on  the  right  ]eg 
and  fore-arm.  The  bones  of  this  limb  united  in  a 
good  position  in  a  few  weeks,  but  the  left  tibia  did 
not  unite  firmly,  and  there  was  considerable  pro- 
jection forward  at  the  seat  of  fracture.  In  March, 
1881,  the  bones  were  again  fractured  at  the  point  of 
partial  union t  and  the  tendo  Achillis  divided.  The 
leg  was  straightened  and  placed  in  a  plaster-of-Paris 
splint.  In  April  there  was  no  formation  of  callus,  but 
by  May  there  was  partial  union  with  bowing  forward 
of  the  tibia.  During  the  next  sixteen  months  she 
wore  a  steel  brace,  but  there  was  no  improvement. 
Dunne  the  month  of  June,  1882,  it  was  twice  fract- 
ured,  but  with  no  effect  as  regards  union.  In  Sep- 
tember, 1882,  an  incision  was  made  down  upon  the 
point  of  fracture ;  the  periosteum  was  found  to  be 
thickened  and  the  ends  of  the  bone  sclerosed.  A 
thin,  wedge-shaped  piece  of  bone  was  removed  from 
the  extremities  of  both  fragments  and  the  ends  of  the 
bones  wired  together,  and  in  two  months  firm  union 
was  established  between  the  fragments.     Porter 8  re- 

1  "Med.  News,"  April  14,  1883,  p.  416. 

2  "  Boston  Med.  and  Surg.  Jour.,"  April  14,  1879,  p.  217. 


OSTEOCLASIS.  161 

ports  a  case  of  anterior  curvature  of  the  tibia.  On  one 
limb  osteotomy  was  performed,  on  the  other  osteo- 
clasis. Five  weeks  after  the  latter  operation  there 
was  found  considerable  overlapping  of  the  ends  of  the 
bones,  and  a  small  fragment  was  found  to  be  mova- 
ble at  the  point  of  fracture,  which  later  became  at- 
tached and  solid,  thus  proving  that  there  had  been 
comminution. 

The  object  of  osteoclasis  is  to  produce  a  simple 
fracture  and  then  to  keep  the  limb,  in  a  fixed  bandage, 
in  a  corrected  position  until  firm  union  has  been  es- 
tablished. With  the  osteoclast  of  Rizzoli  and  Taylor 
the  point  of  fracture  is  certainly  under  the  control  of 
the  operator,  and,  with  the  exception  of  the  two  cases 
mentioned  in  a  previous  page,  I  have  never  heard  of 
any  accident  or  failure  to  correct  in  lateral  and  an- 
terolateral curvature. 

The  result  on  the  bone  itself  has  been  determined 
by  Dr.  A.  T.  Cabot,1  who  obtained  a  specimen  from 
a  patient  who  died  four  months  after  the  operation. 
On  longitudinal  section  of  the  bone,  an  imperfectly 
marked  transverse  line  indicated  the  point  of  fract- 
ure. The  medullary  cavity  was  somewhat  narrowed, 
though  by  no  means  obliterated.  There  was  a  thin 
layer  of  spongy  bone  enveloping  the  tibia  and  ex- 
tending for  an  inch  or  an  inch  and  a  half  above  and 
below  the  point  of  fracture. 

Cases  of  curvatures  of  the  tibia  suitable  for  osteo- 
clasis are  those  of  long  lateral  bends  in  which  there 
is  not  any  marked  anterior  deformity.  Pure  anterior 
curves  I  do  not  think  as  well  suited  for  the  opera- 
tion.   The  danger  of  applying  any  considerable  force 

1  "Boston  Med.  and  Surg.  Jour.,"  18*79,  vol.  ci,  p.  217. 


162  OSTEOTOMY. 

over  the  crest  of  the  tibia  would  seem  a  strong  argu- 
ment against  the  operation  in  this  class  of  cases,  and 
a  fracture  by  lateral  pressure  would  require  a  great 
amount  of  manipulation  of  the  bone  and  disturbance 
of  the  soft  part.  It  has  seemed  to  me  that  a  cunei- 
form osteotomy  was  the  better  operation,  and  really 
to  necessitate  less  injury  to  the  muscles  and  tissues 
about  the  bone.  Dr.  E.  H.  Bradford,  of  Boston,  how- 
ever, uses  the  osteoclast  for  this  description  of  curves, 
and  thinks  well  of  it.  That  the  fracture  is  not  as 
simple  as  when  the  instrument  is  applied  laterally  is 
shown  by  the  comminution  in  Porter's '  case.  Sharp 
curvature  near  the  joint  should  be  corrected  by  a 
linear  osteotomy.  The  dauger  of  injury  to  the  lower 
epiphysis  of  the  tibia  is  great  if  one  of  the  points  of 
counter-pressure  is  directly  on  it. 

The  same  remark  applies  to  sharp  curvatures  just 
below  the  knee  joint. 

In  regard  to  the  age  at  which  osteoclasis  should 
be  performed,  I  think  it  is  a  question  to  be  decided 
by  each  operator  for  himself.  Fracture  of  the  long 
bones  in  children  is  a  trivial  affair.  The  pain  after 
it  is  not  great,  and  by  the  following  day  they  are  as 
merry  as  though  nothing  had  been  done.  In  some 
cases,  while  the  bones  are  quite  soft,  the  deformity 
can  be  corrected  by  simply  bending  the  bones  with 
the  hands  and  then  putting  the  limb  up  in  a  plaster- 
of-Paris  splint.  If  restitution  can  not  be  accomplished 
by  this  means,  it  must  be  left  to  the  surgeon  to  say 
whether  an  attempt  shall  be  made  to  correct  the 
curvature  by  splints  or  by  an  osteoclast.  In  chil- 
dren over  four  years  of  age  I  think,  as  a  rule,  ap- 

1  Loc.  cit. 


OSTEOCLASIS.  1G3 

paratus  is  useless.  In  hospital  practice  I  always 
fracture  as  soon  as  I  am  satisfied  that  the  bones 
are  moderately  hard.  I  have  never  met  with  any 
return  of  the  deformity  after  an  osteoclasis,  and 
in  appropriate  cases  the  correction  is  perfect. 

In  1879 l  an  apparatus  was  presented,  at  a  meet- 
ing of  the  Societe  de  Chirurgie  de  Paris,  for  the  cor- 
rection of  genu  valgum,  devised  by  M.  Collin.  Its 
purpose  was  to  produce  a  separation  between  the 
epiphysis  and  diaphysis  at  the  lower  end  of  the 
femur,  thus  substituting  instrumental  in  the  place 
of  manual  force  in  Delore's  operation.  It  consisted 
of  two  semicircular  collars  or  crutches,  to  be  applied, 
one  to  the  middle  of  the  thigh  and  the  other  to  the 
inferior  third  of  the  leg,  from  their  posterior  aspect, 
and  separated  by  a  frame  movable  at  right  angles  to 
their  long  axis  (porte-a-faux)  by  a  lever,  by  which 
force  is  brought  to  bear  upon  the  knee  joint  from 
within  outward.  This  portion  is  provided  with  a 
well-padded  plate  placed  on  the  inner  side  of  the 
knee.  These  two  semicircular  collars  are  supported 
by  two  iron  rods,  sliding  in  a  steel  groove,  in  order 
to  adapt  them  to  different  limbs.  A  movable  part, 
worked  with  a  long  stem  acting  as  a  lever,  draws  the 
knee  outward,  while  the  two  collars  indicated  above 
hold  the  limb  firm.  In  order  to  prevent  rotation 
of  the  leg,  the  patella  is  held  by  means  of  a  con- 
cave pad,  which  is  set  between  two  uprights  and 
moved  by  a  screw,  so  as  to  be  raised  or  lowered  at 
will.  The  whole  apparatus  is  mounted  upon  a 
thick  piece  of  wood  which  is  made  very  solid  (Fig. 

1  "  Du  genu  valgum  et  de  son  rcdressement  par  l'appareil  Collin."     Braye, 
"  These  de  Paris,"  No.  472,  1880. 


164 


OSTEOTOMY. 


45).  The  power  is  applied  by  means  of  the  long  lever, 
which  draws  the  movable  portion  outward  with  great 
force.  It  has  been  demonstrated  on  the  cadaver  that 
in  all  cases  the  separation  takes  place  invariably  be- 


OSTEOCLASIS. 


161 


tween  the  epiphysis  and  diaphysis,  without  any  in- 
jury to  the  ligaments  or  the  joint.  In  five  limbs  on 
which  the  apparatus  was  used,  in  patients  varying 
from  six  to  fifteen  years  of  age,  the  result  was  excel- 
lent. 

In  1882,  Robin, '  of  Lyons,  exhibited  a  new  osteo- 
clast for  fracture  of  the  lower  end  of  the  femur.  It 
consists  (Fig.  46)  of  an  iron  case  extending  half-way 
around  the  thigh,  on  its  anterior  aspect,  from  a  point  a 


Fig.  46. 


short  distance  above  the  condyles  of  the  femur  up- 
ward to  the  superior  third  of  the  thigh.  Two  steel 
collars  bind  this  to  a  piece  of  heavy  plank — the  one 
at  its  lower,  the  other  at  its  upper  limit.  Each  collar 
is  fastened  to  the  plank  by  a  nut  and  screw.  This 
portion  of  the  apparatus  holds  the  femur  secure.  To 
the  upper  or  superior  portion  of  the  lower  collar  an 
upright  is  securely  fastened,  having   a  slot   at  its 

1 "  Lyon  med.,"  March  26  and  April  2,1882. 


168  OSTEOTOMY. 

upper  part  at  right  angles  to  the  collar  and  parallel 
to  the  long  axis  of  the  limb.  Into  this  slot  is  fitted 
one  end  of  a  lever,  which  extends  down  over  the  leg. 
A  strong  leather  strap,  large  enough  to  surround  the 
thigh  jnst  above  the  condyles  and  pass  around  the 
lever,  completes  the  apparatus.  It  is  evident,  when 
the  osteoclast  is  adjusted,  that  the  lever  will  act, 
when  pulled  upward,  as  one  of  the  second  order 
where  the  weight  is  between  the  fulcrum  and  power. 
The  object  is  to  cause  a  transverse  fracture,  either 
complete  or  incomplete,  just  above  the  epiphyseal 
line  of  the  femur. 

The  following  is  the  method  of  using  it :  The  pa- 
tient having  been  etherized,  and  the  thigh  fastened 
down  by  means  of  the  iron  case,  the  leather  band  is 
placed  around  the  lower  portion  of  the  thigh  so  as  to 
grasp  the  condyles  and  then  pass  over  the  lever.  Just 
before  applying  the  power  the  limb  is  rotated  out- 
ward and  the  force  applied  by  forcing  the  lever  up- 
ward. The  vessels  and  nerves,  being  protected  by  the 
condyles,  escape  any  injury.  With  this  osteoclast  it 
is  found  that  the  fracture  takes  place  just  above  the 
condyles,  and  that  the  correction  of  the  deformity  can 
be  readily  made.  Robin  is  reported  by  Delarue '  to 
have  collected  eighty-three  cases  operated  with  suc- 
cess. In  many  the  operation  was  followed  by  effu- 
sion into  the  knee  joint.  The  time  required  to  ob- 
tain firm  consolidation  was  from  four  to  eight  weeks. 
I  have  had  no  experience  with  either  of  these  instru- 
ments. Their  use  has  been  so  limited  that  but  little 
is  really  known  of  their  merits  in  this  country.     Dr. 

,uDu  redressement  du  genu  valgum."    "These  de  Paris,"  1884,  No.  184, 
p.  49. 


OSTEOCLASIS. 


167 


E.  M.  Moore,  of  Rochester,  has  used  this  instrument 
in  a  case  of  deformity  at  the  knee  joint. 

This  osteoclast,  with  slight  modifications,  has  "been 
used  to  rupture  an  ankylosed  knee  joint. 


ILLUSTRATIVE    CASES. 


Case  I. — George  Ma,  six  years  of  age,  admitted 
into  St.  Mary's  Hospital  for  children  in  May,  1882, 


Fig.  47. 


with  lateral  curvature  of  the  bones  of  both  legs  of 
rachitic  origin.  He  is  a  well-developed  boy,  and  in 
excellent  condition.  Fig.  47  is  from  a  photograph 
taking  shortly  after  admission  into  the  hospital. 

May  15,  1882,  osteoclasis  was  performed  upon 
both  limbs,  the  pad  of  the  instrument  being  placed 
on  the  outer  aspect  of  the  limb  at  the  point  of  great- 
est curvature.  After  fracture  the  limbs  were  put  up 
in  plaster-of-Paris  bandages  in  a  straight  position. 
12 


168 


OSTEOTOMY. 


Patient  did  not  complain  of  much  pain  after  the  in- 
fluence of  the  ether  had  passed  off,  and  at  no  time 
did  his  temperature  rise  above  the  normal. 

June  14th,  splint  removed  and  union  found  to  be 


Fig.  48. 


Fig.  49. 


OSTEOCLASIS. 


169 


firm,  and  the  limb  in  a  good  position.  He  was  al- 
lowed to  get  up.  Fig.  48  is  from  a  photograph  taken 
at  the  time  of  his  discharge. 

Case   II. — Ada   R.,  three   years   of  age,  admit- 
ted into  St.  Mary's  with  rachitic  curvature  of  both 


Fig.  50. 


legs.  She  is  in  good  condition,  and  the  bones  are 
quite  hard. 

Fig.  49  shows  her  condition  at  time  of  admis- 
sion. Osteoclasis  was  performed  on  both  limbs.  They 
were  put  up  in  a  plaster-of-Paris  splint  in  a  straight 
position.  They  were  removed  at  the  end  of  four 
weeks. 

Fig.  50  is  from  a  photograph  at  time  of  dis- 
charge. 


CHAPTER  X. 

STATISTICS  AFTER  OSTEOTOMIES. 

i 

My  experience  in  osteotomy  and  osteoclasis,  al- 
though not  as  extensive  as  that  of  some  European 
surgeons,  yet  has  been  considerable.  For  the  pur- 
poses of  statistics  I  have  divided  all  osteotomies  into 
two  classes,  linear  and  cuneiform.  In  my  judgment, 
the  bone  on  which  the  operation  is  performed  has  no 
influence  on  the  result  except  that  the  more  superfi- 
cial the  bone  the  greater  is  the  liability  for  suppura- 
tion to  follow,  for  the  reason  that  there  is  greater  dan- 
ger of  the  lips  of  the  wound  being  separated  by 
extravasation  of  blood  if  adequate  drainage  has  not 
been  provided.  I  have  performed  seventy-four  linear 
and  seventeen  cuneiform  osteotomies.  All  the  pa- 
tients on  whom  these  operations  were  performed  re- 
covered with  the  deformity  corrected,  except  two 
cases  of  genu  valgum,  on  which  a  Reeves's  operation 
was  done  and  in  which  the  condyle  could  not  be 
detached  on  account  of  the  relaxed  condition  of  the 
external  lateral  ligament. 

The  following  are  the  cases  in  which  suppuration 
occurred : 

In  the  first  case  of  linear  osteotomy  for  bow-legs 
considerable  and  troublesome  suppuration  took  place 


STATISTICS  AFTER  OSTEOTOMIES.  171 

in  both  limbs,  and  from  the  left  a  small  shell  of  bone 
was  detached  from  the  lower  end  of  the  upper  frag- 
ment. During  the  operation  the  anterior  tibial  artery 
was  divided  by  the  osteotome,  which  was  allowed  to 
project  outward  beyond  the  line  of  the  crest  of  the 
tibia.  I  think,  moreover,  that  the  operation  was  not 
performed  properly,  and  that  my  osteotomes  were  too 
thick  ;  there  was  not  sufficient  drainage.  In  the  sec- 
ond, suppuration  occurred  in  one  limb,  but  to  a  slight 
degree.  The  wound  was  not  closed  properly,  and  the 
compress  irritated  the  tissues  of  the  leg.  In  the 
fourth  case  there  was  a  trace  of  pus  for  a  day  or  two, 
and  in  one  patient  a  small  slough  formed  under  a 
compress.  In  the  third  case  of  genu  valgum  after  a 
Macewen's  supra-condyloid  operation  there  was  a  lit- 
tle suppuration  in  one  limb  for  a  few  days.  In  the 
fifth  case  there  was  found,  upon  the  fifteenth  day  af- 
ter the  operation,  a  collection  of  pus  extending  from 
the  wound  up  as  far  as  the  upper  third  of  the  thigh. 
It  was  situated  between  the  muscles  and  the  skin, 
and  did  not  communicate  with  the  bone,  as  stated  on 
page  114.  On  removing  the  small  piece  of  gauze 
covering  the  wound,  a  free  discharge  of  pus  took 
place  and  emptied  the  abscess-cavity.  The  compress 
was  glued  to  the  skin  immediately  around  the  wound 
by  blood,  and  formed  a  portion  of  the  outer  wall  of 
the  abscess-cavity.  I  think  that  the  abscess  had  its 
origin  in  a  small  piece  of  adipose  or  cellular  tissue 
protruding  from  the  lips  of  the  wound ;  this  was  ir- 
ritated by  the  gauze,  and  a  small  quantity  of  pus 
formed;  it  could  not  escape  on  account  of  the  firm 
adhesion  of  the  compress  to  the  skin,  and  the  dried 
blood  on  the  gauze  rendered  it  stiff  and  hard.     It 


172  OSTEOTOMY. 

forced  the  lips  of  the  wound  apart  and,  as  its  quantity 
increased,  the  matter  burrowed  backward  and  upward. 
The  application  of  a  compress  was  soon  followed  by 
a  cure.  The  temperature  in  this  case  did  not  rise 
above  the  normal  until  the  day  on  which  the  abscess 
was  discovered,  and  then  only  reached  100°.  In  the 
ninth  case  a  small  collection  of  pus  was  found  some 
clays  after  the  operation  ;  it  gave  no  trouble,  and  did 
not  retard  convalescence.  The  cause  of  the  abscess 
may  have  been  an  improper  handling  of  the  limb. 

In  the  twelfth  case  quite  an  extensive  collection 
of  pus  occurred  in  the  left  limb,  for  which  no  cause 
can  be  assigned ;  it  did  not  communicate  with  the 
bone,  and  was  easily  controlled. 

I  have  therefore  had  eight  cases  of  suppuration 
in  seventy-four  linear  osteotomies. 

■9 

CUNEIFORM    SECTIONS. 

In  the  first  six  limbs  operated  upon,  suppuration 
took  place  in  all  to  a  considerable  extent,  necessitat- 
ing frequent  dressings.  The  cause  of  this,  I  am  satis- 
fied, was  an  improper  management  of  the  wounds. 
The  pus  in  all  these  cases  was  in  contact  with  the 
bone.  In  three  limbs  there  was  a  slight  necrosis, 
but  all  eventually  made  a  good  recovery,  with  the 
deformity  corrected. 

Since  I  have  managed  the  wound  differently  there 
has  been  no  complication,  except  in  one  case  at  pres- 
ent under  treatment.  It  occurred  in  a  boy,  eight 
years  of  age,  with  a  marked  anterior  curvature  of  both 
tibiae,  and  on  whom  I  performed  a  cuneiform  osteoto- 
my on  both  limbs. 


STATISTICS  AFTER   OSTEOTOMIES.  173 

For  the  first  two  clays  lie  was  continually  in  mo- 
tion, twisting  his  limbs  in  every  direction,  and  which 
it  was  impossible  to  control.  On  the  third  day  both 
legs  were  greatly  swollen,  and  suppuration  followed, 
necessitating  frequent  dressings.  At  the  present  time 
(four  weeks  after  the  operation)  he  is  doing  well.  I 
think  that  in  this  case  suppuration  was  due  to  mo- 
tion between  the  fragments  of  the  bone. 

I  have  lost  two  patients  after  an  osteotomy,  one 
dying  from  diphtheria,  the  other  from  meningitis.  At 
the  time  of  death  firm  union  existed  at  the  point 
of  operation.  The  fatal  issue  in  these  cases  was  in 
no  way  traceable  to  the  operation.  I  have  performed 
osteoclasis  upon  thirty-four  limbs  for  the  correction 
of  lateral  curvature  of  the  tibia.  In  all  recovery  took 
place  without  any  complication,  the  deformity  being 
relieved. 

I  have  been  able  to  collect  the  result  in  fifteen 
hundred  and  ten  (1,510)  cases  of  osteotomy  for  the 
correction  of  deformities  at  the  hip  joint,  for  genu 
valgum  and  tibial  curvature.  Section  for  deformi- 
ties of  the  knee  joint  and  operations  for  vicious  union 
after  fractures  are  not  included,  for  the  reason  that 
these  sections  do  not  strictly  belong  to  the  class  of 
deformities  considered  in  this  volume.  The  labor 
necessary  to  collect  such  statistics,  to  be  of  any  value, 
would  trespass  too  much  on  my  time,  and  would  de- 
lay the  appearance  of  this  volume,  which  has  already 
taken  a  much  longer  time  than  I  had  anticipated  in 
its  preparation.  Of  the  total  number  of  osteotomies, 
fourteen  hundred  and  forty-eight  (1,448)  were  linear 
and  sixty-two  (62)  cuneiform.  Of  the  former,  fifteen, 
(15)  died,  in  ninety-two  (92)  suppuration  is  reported 


174  OSTEOTOMY. 

to  have  occurred,  and  in  seventeen  (17)  there  was 
some  necrosis — a  mortality  of  '010  per  cent. 

Of  cuneiform  osteotomies,  in  seventeen  suppura- 
tion is  reported,  and  five  died — a  mortality  of  "96  per 
cent. 

Taking  the  whole  number  of  operations,  there  was 
a  mortality  of  *0132  per  cent.  There  have,  no  doubt, 
been  other  fatal  cases,  but  no  record  has  been  made 
of  the  fact,  nor  do  these  figures  probably  give  a  fair 
representation  of  the  number  of  operations  that  have 
been  performed. 

Deformities  of  other  bones  have  been  corrected 
by  an  osteotomy,  but  the  number  of  the  operations 
are  few.  Muralt '  and  Schoepff 2  have  divided  the  hu- 
merus for  the  correction  of  deformity  of  this  bone 
after  fracture.  Walton 3  operated  upon  two  cases  of 
ankylosis  of  the  elbow  joint  in  a  straight  line  by  di- 
viding the  humerus.  Barwell4  mentions  another  case. 
Mears6  made  a  section  of  the  humerus  near  the  joint 
in  a  case  of  old  dislocation.  Gardeil  and  Guterbock,6 
and  Hill7  have  divided  the  radius  for  vicious  union 
after  fracture.  In  all  of  these  cases  a  good  result 
was  obtained. 

Taking  into  consideration  the  many  accidents, 
the  want  of  experience  as  to  the  class  of  cases  suit- 
able for  an  osteotomy,  the  faulty  methods  in  opera- 
ting, and  wound  management,  the  results  have  been 
excellent.  If  the  earlier  operations  were  left  out, 
the  mortality  would  be  reduced  to  almost  zero. 

1  "  Campenon,"  loc.  tit.  2  "  Campenon,"  loc.  tit. 

3  "  Lancet,"  April  3,  1880,  p.  226. 

4  "  Treatise  on  Disease  of  Joints,"  2d  ed.,  p.  565. 

5  "Trans.  Am.  Surg.  Assoc,"  vol.  i,  1881-'83,  p.  115. 

5  "  Campenon,"  loc.  cit..        '  "  Lancet,"  1972,  vol.  ii,  p.  153. 


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TIBIAL   CURVES. 

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page  444. 
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ment  par  le  decollement  des  epiphyses,  Lyon,  1874.  / 
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page  137. 
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page  157. 
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vol.  vi,  page  419. 
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de  chirg.,  1881,  page  727. 
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page  885. 
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page  211. 
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1882,  vol.  cii,  page  241. 
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vol.  ii,  page  19. 
13 


INDEX 


Adams's  operation  through  the  neck  of 
the  thigh,  39. 

Adams's  saw,  14. 

Accidents  after  osteotomies  about  the 
hip  joint,  60. 

Age  at  which  rachitic  deformities  are 
developed,  8. 

Angle,  proper  one  for  limb  after  oste- 
otomy for  deformities  at  the 
hip  joint,  31. 

Anchylosis  of  hip  joint  after  rheuma- 
tism, 33. 
of  hip  joint,  30. 
of  knee  joint,  130. 

Anchvlosed  joints,  forcible  rupture  of, 
"  153. 

Bandages,  plaster-of-Paris,  22,  28,  60, 

106,  143. 
Barwell's  operation  for  anchylosis   of 

the  hip  joint,  40. 
operations  for  genu  valgum,  102. 
Barton,  J.  R.    Osteotomy  for  anchylosis 

of  hip  joint,  36. 
Barton's   operation   for  anchylosis  of 

knee  joint,  130. 
Biceps,  contraction  of,  in  genu  valgum, 

87. 
Buck,  Gurdon.    Operation  for  anchy- 

losed  knee,  132. 

Cabot,  Dr.  A.  T.     Case  of  osteoclasis, 
161. 
Case  of  osteotomy,  111. 
Cases  of  osteotomy  for  anchylosis  at  the 
hip  joint,  63. 
of  genu  valgum  adolescentium,  80. 

appropriate  for  osteoclasis,  162. 
of  genu  valgum  appropriate  for  an 
osteotomy,    108. 
Chiene's   operation  for  genu  valgum, 
97. 


Chisel  for  osteotomy,  19. 
Collin's  osteoclast,  164. 
Condyle,  internal  position  of,  in  genu 
valgum,  75. 
external  atrophy  of,  77. 

Death  after  osteotomies,  45,  119,  144. 
Deaths   after   osteotomies   about   hip 

joint,  49. 
Deaths  after  osteotomies  about  knee, 

116. 
Delore.     Redressement  brusque,  150. 

Elbow  joint,  osteotomy  for  anchylosis 
of,  174. 

Fifield's  case  of  non-union  after  osteo- 
clasis, 160. 

Gant's  operation  for  anchylosis  at  hip, 

40. 
Genu  valgum  adolescentium,  80. 

cause  of,  73. 

etiology  of,  78. 

due  to  traumatism,  84. 

femoral,  74. 

uncomplicated  example  of,  71. 

history  of  operations  for,  94. 

infantile,  78. 

partial  excision  of  knee  joint  for,  93. 

double  osteotomy  for,  102. 

cases  appropriate  for  osteotomy,  108. 

Barwell's  operation  for,  102. 

Chiene's  operation  for,  97. 

Macewen's  first  operation  for,  98. 

Macewen's    second    operation,    102, 
105. 

MacCormac's  operation  for,  103. 

Ogston's  operation  for,  95. 

Reeves's  operation  for,  96. 

mode  of  performing  supra-condyloid 
osteotomy,.  105. 


186 


INDEX. 


Genu   valgum,  mechanical   treatment 

of,  88. 

defect,  in  all  operations   upon  the 
condyle,  100. 

tibial,  77. 

theories  of  cause  of,  73. 

statistics  after  osteotomy,  114. 

osteotomy  for,  94. 
Genu  varum,  127. 

Gross's  operation  for  anchylosed  knee 
joint,  184. 

Haemorrhage  after  osteotomy  for  genu 

valgum,  115. 
Hip  joint,  deformities  at,  their  cause,  30 
deformities  of,   after  hip-joint  dis- 
ease, 31. 
deformities  of,  after  dislocation,  33. 
deformities  of,  after  fracture,  34. 
deformities     of.     What     operation 
should  be  performed  ?  50. 
Humerus,  osteotomy  of,  for  deformity, 
174. 

Instrument  required  for  osteotomy,  14. 

Knee  joint,  anchylosis  of ,  osteotomy  for, 
130. 

Langton's  case  of  supra-condyloid  oste- 
otomy, wound  of  popliteal  ar- 
tery, 115. 

Langenbeck's  operation,  12. 

Ligaments,  condition  of,  in  genu  val- 
gum, 78. 

Limb,  management  of,  after  osteotomy, 
22,  28,  67,  106,  142. 

Listerism  and  osteotomy,  13,  19. 

Little's  operation  for  anchylosis  of  knee 
joint,  134. 

Macewen's  first  operation  for  genu  val- 
gum, 98. 
second  operation  for  genu  valgum, 
102. 

MacCormac's  operation  for  genu  val- 
gum, 103. 

McGill's  case  of  division  of  popliteal 
artery  in  supra-condyloid  oste- 
otomy, 115. 

Macnamara  on  rickety  bones,  5. 

Maisonneuve's  operation  through  the 
neck,  39. 

Mechanical  treatment  of  genu  valgum, 
one  cause  of  the  failure  of,  88. 

Method  of  management  of  limb  after 
an  osteotomy  about  the  hip 
joint,  67. 


Mid-femoral  osteotomy  for  genu  val- 
gum, 103. 

Moore,  Dr.  E.  M.  Case  of  osteotomy 
at  the  hip,  52. 

Mortality  after  osteotomy,  173. 

Motion  after  osteotomies  about  the  hip 
joint,  57. 

Occipital  bone,  alterations  in,  4. 
Ogston's  operation  for  genu  valgum, 

95. 
Osteotome,  description  of,  16. 

manner  of  using,  19. 
Osteoclasis,  149. 
for  rachitic  curvature  of  the  bones 

of  the  legs,  157. 
for  tibial  curvatures,  157. 
for  deformities   of    the  long  bone 
after  fracture,  156. 
Osteoclast,  Collin's,  164. 
Rozzoli's,  154. 
Robin's,  165. 
Osteotomy,  definition  of,  11. 
instruments  for,  14. 
history  of,  12. 
method  of  performing,  19. 
subcutaneous,  19. 
by  open  wound,  26. 
cuneiform,  26. 

for  deformity  at  the  hip  joint,  his- 
tory of,  36. 
at  hip  joint,  when  it  should  be  per- 
formed, 51. 
of  the  femur  for  deformities  due  to 
vicious    union    after    fracture, 
61. 
linear,  for  anchylosis  of  knee  joint, 

134. 
of  neck  of  femur,  39. 
inter-trochanteric,  38. 
below  trochanter  minor,  40,  43. 
for  deformity  of  the  knee  joint,  130. 
for  deformities  after  fracture  of  the 

bones  of  the  leg,  138. 
for  genu  valgum,  94. 
cuneiform,  of  the  tibia.  142. 
for  curvature  of  the  tibia  and  fibula, 

136. 
for  genu  valgum,  suppuration  after, 

114. 
for  deformity  of  the  humerus,  174. 
for  deformity  of  the  elbow,  174. 
for  deformity  of  the  radius,  174. 

Pain  after  osteotomies,  26. 
Parker,  Rushton,  osteoclasis,  152. 
Post's,  Dr.  A.  C,  fatal  case  after  oste- 
otomy, 60. 


INDEX. 


187 


Radius,  osteotomy  of,  for  deformity, 

174. 
Redressernent  brusque,  150. 
Reeves's  operation  for  genu  valgum,  96. 
mid-femoral  operation  for  genu  val- 
gum, 103. 
Rickets  not  confined  to  children  of  the 
poor,  2. 
symptoms  of,  2. 
its  relation  to  deformities,  2. 
acute,  8. 
Rizzoli's  osteoclast,  154. 
Robin's  osteoclast,  165. 
Rodger's,  J.  K.,  operation  for  defor- 
mity at  hip  joint,  36. 

Sands,  Dr.  H.  B.,  on  motion  after  os- 
teotomy about  the  hip  joint,  58. 
Statistics  of  osteotomies  about  the  hip 
joint,  44. 

of  osteotomies,  personal,  1*70. 

of  operations  upon  the  tibia,  145. 

of  osteotomies,  general,  173. 
Shrady  saw,  15. 
Saw,  Adams's,  14. 

Shrady's,  14. 

objections  to,  15. 


Sayre's,  L.  A.,  line  of  section  between 
the  trochanters,  37. 

Servais.     Case  of  osteotomy,  61. 

Smith's,  Stephen,  operation  for  de- 
formity at  the  hip  joint,  41. 

Suppuration  after  osteotomies,  CO,  114, 
170. 

Taylor's,  Dr.  C.  T.,  osteoclast,  150. 
Temperature  after  osteotomy,  25. 
Tibial  spines,  83. 

Tibia  and  fibula,  curvature  of,  136. 
osteotomy  for  deformities  after  frac- 
ture of,  137. 

Volkmann.  Operation  between  the  tro- 
chanters, 38. 

Wedge,  method  of  removing  one,  27. 
method  of  determining  size  of,  in 
cuneiform  osteotomy,  27. 
Wharton's,  Dr.  H.  R.,  case  of  osteoto- 
my of  the  hip,  62. 
Wound,  Macewen's  method  of  manage- 
ment of,  24. 
management    of,    after   ostcotomv, 
22. 


A  DICTIONARY  OF  MEDICINE, 

INCLUDING 

GENERAL    PATHOLOGY,  GENERAL  THERAPEUTICS,   HYGIENE, 

AND  THE   DISEASES   PECULIAR  TO  WOMEN   AND 

CHILDREN. 

BY   VARIOUS    WRITERS. 

EDITED   BY 

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meaning  has  been  given  to  the  word  Medicine.  To  the  general  practitioner  we  can 
most  heartily  recommend  the  work  ;  and  it  will  find  many  readers  outside  the  pale 
of  the  medical  profession.  It  should  have  a  place  in  at  least  every  public,  if  not  in 
every  good  private,  library." — Saturday  Review. 

"  The  articles  we  have  read  have  struck  us  as  models  of  clear  and  fluent  scientific 
English.  The  volume  contains  many  articles  on  matters  of  general  interest  to  the 
public  at  large,  though  not  less  important  on  that  account  to  the  practitioner." — Lon- 
don Spectator. 

New  York;  D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street. 


NOW  READY,  A   NEW  EDITION  OF 

Lectures  on  Orthopedic  Surgery 
and  Diseases  of  the  Joints. 

By  LEWIS  A.  SAYRE,  M.  D., 

Professor  of  Orthopedic  Surgery  and  Clinical  Surgery  in  Bellevue  Hospital  Medical  College ; 

Consulting  Surgeon  to  Bellevue  Hospital,  Charity  Hospital,  St.  Elizabeth's 

Hospital,  Northwestern  Dispensary,  etc.,  etc. 

Illustrated  with  324  Engravings  on  Wood.     1  vol.,  8vo.  Cloth,  $5.00; 
sheep,  $6.00. 


"  This  edition  has  been  thoroughly  revised  and  rearranged,  and  the  subjects 
classified  in  the  anatomical  and  pathological  order  of  their  development.  Many 
of  the  chapters  have  been  entirely  rewritten,  and  several  new  ones  added,  and  the 
whole  work  brought  up  to  the  present  time,  with  all  the  new  improvements  that 
have  been  developed  in  this  department  of  surgery.  Many  new  engravings  have 
been  added,  each  illustrating  some  special  point  in  practice." — Author. 

NOTICES  OF  FORMER  EDITIONS. 

"The  name  of  theautboris  a  sufficient  euarantee  of  its  excellence,  as  no  man  in  America 
or  elsewhere  lias  devoted  such  unremitting  attention  for  tbe  past  thirty  years  to  this  depart- 
ment of  surgery,  or  ^iven  to  the  profession  so  many  new  truths  and  laws  as  applying 
to  the  pathology  and  treatment  of  deformities." — Western  Lancet. 

"Dr.  Sayre  has  stamped  his  individuality  on  every  part  of  his  book.  Possessed  of  a 
taste  for  mechanics,  he  has  admirably  utilized  it  in  so  modifying  the  inventions  of  others 
as  to  make  them  of  far  greater  practical  value.  The  care,  patience,  and  perseverance 
which  he  exhibits  in  fulfilling  all  the  conditions  necessary  for  success  in  the  treatment 
of  this  troublesome  class  of  cases  are  worthy  of  all  praise  and  imitation." — Detroit  Review 
of  Medicine. 

"Its  teaching  is  sound,  and  the  originality  throughout  very  pleasing;  in  a  word,  no 
man  should  attempt  the  treatment  of  deformities  of  joint  affections  without  being  familiar 
with  the  views  contained  in  these  lectures." — Canada  Medical  and  Surgical  Journal. 


RECENTLY  ISSUED,  A  NEW  EDITION  OF 

A  Praetieal  Manual  on  the  Treat- 
ment of  Club-Foot. 

By  LEWIS  A.   SAYRE,  M.  D., 

Professor  of  Orthopedic  Surgery  in  Bellevue  Hospital  Medical  College;  Surgeon  to  Belle- 
vue and  Charity  Hospitals,  etc. 

Fourth  edition,  enlarged  and  corrected.    1  vol.,    12mo.     Illustrated. 
Cloth,  $1.25. 


"  The  object  of  this  work  is  to  convey,  in  as  concise  a  manner  as  possible,  all 
the  practical  information  and  instruction  necessary  to  enable  the  general  practi- 
tioner to  apply  that  plan  of  treatment  which  has  been  so  successful  in  my  own 
hands." — Preface. 

"  The  hook  will  very  well  satisfy  the  wants  of  the  majority  of  general  practitioners, 
for  whose  use,  as  stated,  it  is  intended."— New  York  Medical  Journal. 


New  York  :  D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street. 


August,  1884. 


EQedical  aijd  §ygiei]ic  Illorks 


PUBLISHED    BY 


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the  Practitioner.     Third  edition.     8vo Cloth,  $5.00*;  Sheep,     6  00* 

BARTHOLOW'S  Treatise  on  Materia  Medica  and  Therapeutics.  Fifth 
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On  the  Antagonism  between  Medicines  and  between  Remedies 

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8vo Cloth,     1  25* 

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BILLINGS  (F.  S.).  The  Relation  of  Animal  Diseases  to  the  Public 
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BILLROTH  (Dr.  THEODOR).  General  Surgical  Pathology  and  Thera- 
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2 

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BUCK  (GURDON).  Contributions  to  Reparative  Surgery,  showing  its 
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Illustrated  by  Thirty  Cases  and  fine  Engravings.     8vo Cloth,     3  00* 

CARPENTER  (W.  B.).  Principles  of  Mental  Physiology,  with  their 
Application  to  the  Training  and  Discipline  of  the  Mind,  and  the 
Study  of  its  Morbid  Conditions.  By  William  B.  Carpenter,  M.  D., 
etc.     12mo Cloth,     3  00 

CARTER  (ALFRED  H).  Elements  of  Practical  Medicine.  By  Alfred 
H.  Carter,  M.  D.,  Member  of  the  Royal  College  of  Physicians,  Lon- 
don; Physician  to  the  Queen's  Hospital,  Birmingham,  etc.  Third 
edition,  revised  and  enlarged.    1  vol.,  12mo.    (To  oe  published  soon.) 

CHA UVEAL"  (A.).  The  Comparative  Anatomy  of  the  Domesticated 
Animals.  Translated  and  edited  by  George  Fleming.  8vo.  Illus- 
trated   Cloth,     6  00 

COMBE  (ANDREW).  The  Management  of  Infancy,  Physiological  and 
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James  Clark,  Bart.,  K.  C.  B.,  M.  D.,  F.  R.  S.     12mo Cloth,     1  50 

CORNING  (J.  L.).  Brain  Exhaustion,  with  some  Preliminary  Consid- 
erations on  Cerebral  Dynamics.  By  J.  Leonard  Corning,  M.  D., 
etc.     Crown  8vo ' Cloth,     2  00 

DAYIS    (HENRY    G.).      Conservative   Surgery.     With  Illustrations. 

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ELLIOT  (GEORGE  T.).  Obstetric  Clinic :  A  Practical  Contribution  to 
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By  George  T.  Elliot,  Jr.,  A.  M.,  M.  D.     8vo Cloth,     4  50* 

EYETZKY  (ETIENNE,  M.  D.).  The  Physiological  and  Therapeutical 
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FOURNIER  (ALFRED,  M.  D.).     Syphilis  and  Marriage.      Translated 

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FREY  (HEINRICH).  The  Histology  and  Histochemistry  of  Man.  A 
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Human  Body.  By  Heinrich  Frey,  Professor  of  Medicine  in  Zurich. 
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HAMMOND  (W.  A.).  A  Treatise  on  Diseases  of  the  Nervous  System. 
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tired).    Seventh  edition,  rewritten,  enlarged,  and  improved.     8vo. 

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of  Medicine,  Edinburgh,  etc.  With  Preface  by  Alexander  J.  C. 
Skene,  M.  D.,  Professor  of  the  Medical  and  Surgical  Diseases  of 
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MARKOE  (T.  M.).  A  Treatise  on  Diseases  of  the  Bones.  By  Thomas 
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and  Surgeons.     With  Illustrations.     8vo Cloth,     4  50* 

MAUDSLEY  (HENRY).  Body  and  Mind:  an  Inquiry  into  their  Con- 
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SAYRE  (LEWIS  A.,  M.  D.).  Practical  Manual  of  the  Treatment  of 
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Dr.  Walter  B.  Piatt,  F.  R.  C.  S.  (Eng.).  {Nearly  ready) 

VAN  BUREN  (W.  H.).  Lectures  upon  Diseases  of  the  Rectum,  and 
the  Surgery  of  the  Lower  Bowel,  delivered  at  Bellevue  Hospital 
Medical  College,  by  W.  H.  Van  Buren,  M.  D.,  LL.  D.  New  edition, 
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VAN  BUREN  and  KEYES.  A  Practical  Treatise  on  the  Surgical 
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VOGEL  (A.).  A  Practical  Treatise  on  the  Diseases  of  Children.  By 
Alfred  Vogel,  M.  D.,  Professor  of  Clinical  Medicine  in  the  Univer- 
sity of  Dorpat,  Russia.  Translated  and  edited  by  H.  Raphael,  M.  D. 
From  the  fourth  German  edition.  Illustrated  by  six  Lithographic 
Plates.     8vo Cloth,  $4.50*;  Sheep,     5  50* 

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WALTON  (GEORGE  E.,  M.  D.).  Mineral  Springs  of  the  United  States 
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WYLLE  (WLLLIAM  G.).     Hospitals :  Their  History,  Organization,  and 

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